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Waste Tire Sufty & Inspection Repor Inspection Report Number <br /> . . -- _ <br /> �'� � � State of California ■ <br /> CIWMB 181( eaSurvey Form - Page 1 :i L - 1 0 2 5 5 l 4� , <br /> i. <br /> California Integrated WasttM <br /> Waste Management Board ....... ..... _.) <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> , I ME �t �Jim <br /> ar"as f 6 ° ")�Fl�,��rLr <br /> "�,. �).rQ 41 ++ wa, '.�$?x"�-" ,�a ,+sire "7 y e i <br /> TPID <br /> - Inspection Type (Fill one) <br /> Site <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral Observation ' <br /> Local ^� If Referral,choose referral type(Fill one) <br /> Identifier: G.C' /� 0 CHP [� CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - - <br /> Business or Facility Name Inspector Inspected By <br /> , nG( _ <br /> Physical Address ^� ! I ��� �u f <br /> L NC)30y. a r (✓Cl" _kC <br /> Street <br /> Inspection Date V <br /> City State 7_1P Code Time In Time Out <br /> L-E] <br />' Business Rep Title <br /> E�]0 AM [:E] : [T ' Q AM <br /> tyle, PM OPM <br /> '7- +L��t o r �r _ <br /> Operational Status Tire"Type �; Business Role Storage Type <br /> r.? � <br /> (Fillone only) (Fill all that app ) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenge ,) 0 Generator 0 Outdoor <br /> O ® Closed 0 Altered 1 <br /> r 'SPS Latitude ! "f 0 Hauler 0 Indoor <br /> 0 Inactive 0 "ruck <br /> �— O <br /> Longitude - i <br /> 0 Planned QOi;r; ' 0 End-Use 0 Container <br /> Business Type-(Fill all that apply) ' <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other IY10 t1' rUC uC�ji <br /> - - <br /> Part <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORGEMENT,.STATUS a <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Q'Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements bate <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 0 m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) _ <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments .U/S 60(lily log 0, ►'l l? al- d <br /> a - ill Of OtTCS' 1y'kl )rd <br /> e d"Ore oo the totevyi;_-)e, APl. bLAI1r.!;n'' b�/(�'�-I <br /> Q o C a f e j. -�o ��rel f t°(d T U�'U��� `a r'�� ©t` ' Y t i S j Ut f i t I C t t U 4�1 _Yl C�'E <br /> I07, <br /> nSpeCtlonForm Included 4 Ebur „.,Ku/ „iz� <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> I <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: �/ �, ,„�, =° ”. I <br /> White Copy:CIWM6 Yellow Copy:Operator Pink Copy:LEA ■ <br />