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ns ectlon Report Number <br /> Waste Tire Su y & Inspection Report* pp <br /> 0 StateB California Survey Form - Page 1 i - 1 0 10 <br /> CIWMB 1S1(New 04/04) +; <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> ti <br /> TPID- U F ��Ol/1 _ r } Inspection Type (Fill one) <br /> Site Suffix: 1 1 x J ( �,� ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - !1 �c If Referral,choose referral type(Fill one) <br /> Identifier: `' f'' ��} `(i t .'j L� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 1 i 4- r:;, f 1___tL(" '. t, !;, {• 0 <br /> Street w <br /> t Inspection Date <br /> City State ZIP Code TimeIn Time Out <br /> Business Rep Title -_._. --- - 0 AM - 0 AM <br /> _.. 0 PM : F70 PM <br /> fl ,tr�fr jl t <br /> �d. <br /> Operational Status Tire Type I Business Role Storage Type <br /> (Fill one only) (Fill all that ap � (Fill all that apply) (Fill all that apply) <br /> „Tire Count(Wh61e1PT5) <br /> } live 0 Passenger 0 Generator 0 Outdoor <br /> m O 0 Closed 0 Altered <br /> GPS Latitude I I . -- —� 0 Hauler 0 Indoor <br /> U 0 Inactive ' 0 Truck <br /> Longitude 0 Planned 0 QTR <br /> 0 End-Use 0 Container <br /> _ <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 /> tij , <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other i t,t I�(" 1 ; �/) I r, ({(s r t •-4 k <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> i <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 Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 (a)(b),(c)-Tire Program ID Number from CIWMB <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 0 In Compliance - No Violations <br /> 0 0 Other: <br /> - -- — <br /> Comments - <br /> i. i... ( 4i,f) +l:}t "`. ��'+{.{� l+ � r `_t •elf iY.(.l(�� 4iv'-1 ��f ,}1 +�i'�.( <br /> IU <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Nurnber <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�, X 4, .0.1�,,-, 1. _ ; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />