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Inspection Report Number <br /> Waste Tire Sy & Inspection Repor <br /> 9077- State of California D <br /> �Af ,(f j/�� +'� <br /> w 04104) <br /> California Integrated CIWMB 1Waste 81 eManagement Board Survey Form - Page 1 7 - 1 0 { 0 7 5 5 <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> TPID- �k - Inspection Type (Fill one) <br /> Site Suffix: j �� I Q Routine Q Re-inspection Q Referral Q Observation <br /> Locali If Referral,choose referral type(Fill one) <br /> Identifier: r <br /> . b` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> r--•-•f - ;• j• ; -; Inspection Date <br /> City r- -' State ZIP Code Time In Time Out <br /> Business Rep Title ( O AM a] Q AM <br /> L—A 0 PM0 PM <br /> f r (' I T• <br /> Operational Status Business RolekOs <br /> (Fill one only) �' tl, l�k%akelY�� (Fill all that apply) Fli i tat,1 pl ), <br /> Q Active �sQi( SY4gT°G Q Generators <br /> GPS Latitude <br /> 0 Q Closed � ( �r,F«fir", <br /> ia; M41Y�r" i" r��"+rd,a rby+I Q Hauler <br /> O Qom- inactive r��,`��i&'✓ ^!rr t,i Y�o� �rrar "'ar f h <br /> Longitude - �iF �r� ,""�stsfi: Q End-Use ir `�1'�E1t '+ <br /> 9 Q Planned <br /> $USI' <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 Other I-T p{f.: 'j. T{r: <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 /> l 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 Q In Compliance - No Violations <br /> Q Q Other: ------- <br /> Comments <br /> r <br />— ! l <br /> FF <br /> 5� <br /> Nrr,,� � <br /> ri I ru n t T �1nr u r srl r 4S1Ft r +k# [kms fA �r 2 P y� <br /> I'rrL?',.. ..� . <br /> - 62081 <br /> INSTRUCTIONS ON BACK '`Correct: Incorrect �? , P! 1 " <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />