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or Inspection Report Number <br /> Waste Tire S y & Inspection Rep : <br /> WID33.0 State B California ( . i <br /> Cgrated 1st(New <br /> Mana a Survey Form - Page 1 <br /> California Integrated Waste Management Board Y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> mw. <br /> n l a„,a zn f,iNat r ;aa N a i ihi rc P <br /> :w,<,.. <br /> :.”'r .mt :,����,�Awu�> -..,w„�,,sr;� .,: <br /> TPID- _,--- -_- ( _-- Inspection Type (Fill one) — -- <br /> Site Suffix: I = - f <br /> ' (3 Routine O Re-inspection 0 Referral 0 Observation <br /> Local r 1 t`^r If Referral,choose referral type(Fill one) <br /> Identifier: t�+(t 4, j t;+ <br /> OCHP OCIWMB OCom taint <br /> O Educational Visit O Other <br /> Business or Facility Name h <br /> Inspected By - _ Inspector <br /> Physical Addressf ) io,! t (y <br /> Street -- <br /> �` / Inspection Date <br /> State ZIP Code <br /> city e Time In _ _ <br /> _ Time Out <br /> Business Rep Title 0 AM <br /> / —� ! t—� � • 0 A <br /> t' <{t��-ia ,,-`( i; 0 P 0 PM i <br /> Operational Status r n "raiw Business Role fir, <br /> 1 r ��r ,1 <br /> t / (Fill one only) t, j(, Itn1 (Fill all thataPPY) ((rt)I, ilrkl'�#spply) <br /> O Active O Generator <br /> Closed ¢i �r x"/r �"w`tar "' fw�"✓r r'++w'a�w r <br /> GPS Latitude O <br /> ew r"" air d O Hauler <br /> G yP, re r <br /> O Inactive <br /> Longitude - O Planned O End-Use , <br /> O <br /> , <br /> I t <br /> "r G� i Xpw rwd r Y <br /> ,^� <br /> _ ill If <br /> O New Tire Dealer O Auto Repair 0 Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility r c_ y ENFORCEMENT STATUS I <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § In Compliance - No Violations <br /> ------—-- -- -- ----. ---- _.- <br /> Comments <br /> r"' r 'fit ' �r�`•` t l <br /> r 1 T <br /> Inspection Form 'Included: O <br /> Comments Included: O <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: X <br /> Incorrect: i � ( <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />