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Waste Tire Su0by & Inspection Report Inspection Report Number ■ <br /> State of California jf�t j �f�j �J} <br /> Z � CIWMB 181(New <br /> Manage) Survey Form - Page 1 , V 1 V 1 0 6 4 i <br /> California Integrated Waste Management Board -- __--_ - -_ <br /> Part A Survey BLUE OR BLACK INK PEN <br /> � 9fi a �wf _ /s nai �a 9 sa k _r#.4 z� F 'r ��IiAf PPrttl. .. <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix Gt �C S lr` I Routine O Re-inspection Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> )a (i yt ( Q CHP Q CIWMB Q Complaint 0 Educational Visit 0Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressD <br /> /h r <br /> Street <br /> 2, Inspection Date i- _2 <br /> f C Time In Time Out <br /> City State ZIP Code ._. _ _ <br /> Business Rep Title 0 AM O AM <br /> O PM O PM <br /> �J I <br /> Operational Status Business Role rF � <br /> 7 (Fill one only) )(''aIM � (Fill all that apply) p� ) e <br /> �� <br /> Q Active �Gent I Q Generator ,b�o�µ" <br /> .9 airr qa r)=' A✓ " n r A � C r of w"ar� ✓r t �a�a(a q P i <br /> t lw r r ra 1 i r"wf rJwrk d,+ywq a✓ao rlrl <br /> rt wNt 1 rack i>a"t� rw <br /> Closed <br /> Latitude <br /> ........... <br /> GPS Hauler <br /> LjO Inactive 4 t w p✓rrvw wr <br /> I rw <br /> r <br /> wru^,.'' ak✓�Tw r}'��4wrw t <br /> Longitude — <br /> Planned t "tr y End Use Cbt1f")t9er' r <br /> pL K M1 (A <br /> w'",t'� r'i'"?.s�,....� ,.rC.';, � L _+,.+� 'r^'Y•.`'{nl'r,r<t' w Yr;na_nsa.. u7),$.,. .0 i� sL."i4r. rrw~',I.°ei 9try w Yr i:e'Y n^ a e fw, :. °:w .?.i iaMt' <br /> O New Tire Dealer O—Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station O Hauler O 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 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date Fr] <br /> / 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'orEXT) <br /> O 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 Q 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 In Compliance - No Violations <br /> O O Other: §_--- ----- - - - -- _-_ <br /> Comments } <br /> � n.f _ <br /> C2—I/ yl&. sJr <br /> r it U,�t <br /> r n a'r�. a : r .r � tc o € .� ✓l w ,r , a w r Y, r r r r r <br /> Po P <br /> k <br /> " M�"7 ,ttaf`'s�ig ature �ftone NIl!'Tl Iyer " <br /> / . H . <br /> INSTRUCTIONS ON BACK Correct: incorrect: X �i V 62081 <br /> WhiteYellow <br /> .._ _.. _ .....-.__.,,..,.._ ...�,. ...... . ■ <br /> ■ _ - ll - <br /> Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />