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Waste Tire S & Inspection Repo ...spection Report Number <br /> State B California a ! <br /> CIWMB 181(New ) Survey Form - Page 1 - 0 {J <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> a ,t 11► ,13ekk41 <br /> tJ. u"5 'tftt�' tFWr,. a', * ✓r; " :b ; ..g �u'.�eL;nr.;:.. .x�.,.! <br /> TPID- - Q ' Inspection Type (Fill one) <br /> Site Suffix: �j <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier <br /> _��`(�� U� �� C�L2 i1_ c• Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Ins ected B <br /> p y Inspector <br /> Physical Address <br /> L l"�6"(i'! L 1 C L 1 I <br /> 150C) El <br /> Street / <br /> (6 2` Inspection Datenocd <br /> / t� <br /> y <br /> ( --q�l�X 00 ( ) ."_t" <br /> City State ZIP Code <br /> Time In Time Out <br /> Business Rep Title AMOAM <br /> �L� ;f ., O PM f t O PM <br /> V11 C-1 <br /> Operational Status , �i Business Role5f � <br /> r.� (Fill one only) +,,° 1�, +� (Fill all that apply) <br /> 1 <br /> t w a M <br /> Active ,oyf ` @ Generator <br /> ' Q �a� a "9 <br /> GPS Latitude <br /> O ""r+�✓ "�"�*✓1"ra,� � � �J"����",it�tr�°�a��,� <br /> Q Closed �fi <br /> Hauler <br /> Q Inactive <br /> Longitude - �? QE <br /> Q Planned nd-Use��r � �� � ,'"✓����"��Mdt <br /> ^;., ^ m .,..:� � 4�.,:'u r ,'�; r✓ ,., Vr a 'r��,i r��p�y��i�����,l;d rti �/y��ry`'i'�r w'I� "i , �'� ✓ < '�'•�, "",,�J��'��31,�b+u"i��. <br /> . . ..r <br /> ire Dealer Q Auto Repair ®eTrucking Fleet Q>r,..Government 0 <br /> u✓Rdr^hetreade„r Q.CalDi2smyaian�.tc.ler .rl' a✓.rQ. Tire JDreraive>'dt.Fu <br /> el ire <br /> i-f <br /> Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> QQ 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § ------- <br /> Comments t !/ ,,// .. <br /> ot, tl+ �Yi//_ +1 f ii4'fl �i•1l �v1..j t /L JJ f�l✓!,.I (�(�CI �,'t f <br /> !t0tit/I 1i b'1'1 '_ /fir LVW ji(� Y 1'r�'ii3Vet L( ,(%�''b � _ � 4¢ { <br /> �— 1 1 v f b 1.�}' VC _ t✓J- � () AUX, �._ <br /> ft w oyu a ✓ a to fi drys a�)Clv1 tuna--- rr- wt.;V( t Gl <br /> I ltlycioe .yieojed. (9h aeld _320 vuo J( f�r��, ko w i., tr c, <br /> INSTRUCTIONS ON BACK Correct:l Incorrect: I d 62081 <br /> Y <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />