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Waste Tire Sy nspection Repor Inspection Report Number <br /> & I <br /> EE7. _-.- ..... <br /> State of California <br /> ClWMB 181 0410 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 1 9 - 10 10 5 7 5 '. <br /> Part A-Sury2y BLUE OR BLACK INK PEN <br /> 12jW._s u P"(tt" <br /> TPID- 41 � — Inspection Type (Fill one) <br /> Site Suffix: I / I t <br /> f -` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local i..•0 If Referral,choose referral type(Fill one) <br /> Identifier: 1"�i ! y�[ ,( ; f`' ( f, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 7 -- <br /> I �j _ <br /> Physical Address j .�� 1 � (-; � I •.,�f111��rl,t. I��IC>�. <br /> '' r.: `` 1 <br /> I I <br /> Street <br /> Inspection Date Q� ` <br /> City State ZIP Code Time_In Time Out <br /> Business Re r <br /> P Title O AM O AM <br /> O PM O PM <br /> J' l(5{E I. , I I r <br /> NEIREMMIIIIIIII 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 /> ire G'ount(Wfio e1PTE) <br /> (a Active Q Passenger ® Generator Q Outdoor <br /> Latitude m I O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> D Q Inactive Q Truck I <br /> Longitude — <br /> g J, <br /> Q Planned Q OTR ', Q End-Use Q Container <br /> Business Type (Fill all iia apply" <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire 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 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 M / M / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears - -- <br /> Q Q § P 9 Y i <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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ,D / <br /> t !: , ! �� 1..�J_ t ► u��J ! 1 r- r�1�i.t j <br /> t, tt �t! `t.rri � f-loul�.Ef <br /> /_j a �jt 0� /1 f p C.f i/�{,J� J"A - <br /> _,, 1 C I t.��` I t Sp I C t�1 Yl� ^ ,_Lt rl �l.' ! t� 1 / ,t o <br /> in i" Y1 'included: -- <br /> - i <br /> Comments Included: Q" <br /> Business Rep's Signature phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X , ,�,�, p �j L 1 , _ 3 6208 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />