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Waste Tire SLOY & Inspection Reporiftspection Report Number <br /> State B California i ® � <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 1 <br /> California Integrated Waste Management Board J J -- <br /> 8390 <br /> Part IA Survey µ „* _ BLUE OR BLACK INK PEN <br /> t inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local E / f If Referral,choose referral type(Fill one) <br /> Identifier. %C ._f / tf0 CHP 0CIWMB oComplaint oEducational Visit 0Other <br /> Business or Facili,ty Name <br /> Inspected By Inspector <br /> J(,r 1 l -� OC. <br /> Physical Address <br /> tit.,,r- br I <br /> Strut _. Inspection Date 0(�A '.-) �/ <br /> State ZIP Code Time In Time Out <br /> Business Re <br /> - p ��c r, ,= .Title : �_ O AM � O AM <br /> J &t'I V. ..; +i.F-� — QPM QPM <br /> pp" <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply): (Fill all that apply) (Fill all that apply) <br /> M <br /> o Active 0 Passenger o Generator 0 Outdoor <br /> i p . - - — OGPS Latitude Closed Altered <br /> Il—moi JI l I Q Hauler a Indoor <br /> O <br /> O o Inactive C Truck <br /> Longitude - 0 Planned OTR o End-Use Container <br /> Business Type (Fill all that apply) <br /> o New Tire Dealer Q Auto Repair o Trucking Fleet o Government Q Retreader o Dismantler o Tire Derived Fuel <br /> Q Used Tire Dealer o Auto Body Q Car Dealer o Collection Q Crumb Rubber <br /> o Service Station o Hauler o Agriculture Q Shredder o Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j,HAULING AND MANIFEST REQUIREMENTS o Notice Of Violation Q Extension <br /> 0 o PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 o PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m /-m <br /> o o 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O § p p g y (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 14 CCR 18459.2.1 -Submittal of Com rehensive Tri Lo s within 90 da s <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (ED In Compliance - No Violations <br /> 0 o Other: § <br /> Comments ,7 <br /> ��1,.- � �C (,t - � C c' F' _ -f c.-t Y�'�IYE� {,r� '.:riitc�l�:-. �� '✓(,,� f't. � <br /> ! <br /> i '^ t5 r <br /> ��k6 7. r t C'FL V;e vvetA <br /> Lj <br /> ��1Cr ` , l�'j s J o,-(' 6! (i{{'i 1 S 7 !�( Cfi{r1 <br />} <br /> C7 t P t%r T f y,r (-t"�7 <br /> d: QIns miction Form Include , 4 <br /> _ <br /> Comments Included: o a <br /> Business Rep'g Signature Phone Number inspectors Signature , Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: A M P( �KI <br /> T1 2 �1 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />