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Waste Tire Su. y & Inspection Report nspection Report Number <br /> 1171 State oCIWMBf California6 - 1006389 ry <br /> 0410 <br /> California Int grated'Wast(Newof <br /> Board Survey Form - Page 1 1 V - 1 0 VjJ'�� V 3 Q V 9 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: ( l l O 7I ! J 3 I �J - I f g Routine Q Re-inspection Q Referral Q Observation <br /> Local �--� �_ If Referral,choose referral type(Fill one) <br /> Identifier: /--� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I - <br /> Business or Facility Name Inspected By Inspector <br /> ��' <br /> Physical Address ( I l I I I(::S:, ,7#- <br /> l `A' <br /> treet Inspection Date <br /> I /" <br /> City State ZIP Code <br /> ) P , J Time In Time Out <br /> 0 AM <br /> 0 AM <br /> Business Rep Title ( �I �� � I z I �, �;PM © I �j I � �I �I ®PM <br /> I <br /> t <br /> !� �. ?.,,�i 11 I - - ---- <br /> Operational Status Tire Type Business Role forage Typ <br /> e Count (Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) fill all that ap <br /> ® Active Q Passenger Generator Outdoor <br /> GPS I I I I Q Closed Q Altered <br /> Latitude <br /> Hauler door <br /> Q Inactive Q Truck <br /> Longitude - v. Q Planned OTR Q End-Use onta <br /> rti iner <br /> Buy 5 pe (Fill <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 /> V1 A HAULING AND MANIFEST REQUIREMENTS <br /> -- Q Notice Of Violation Q Extension <br /> ® Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 / T <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 /> 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 !"_ L= �/ r <br /> '1`J,it-- <br /> 1 ; <br /> Inspection Form Included: Q <br /> Comments Included: - - <br /> QI Business Rep's Signature Phone Number -Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X Ak ��I E`XI' MI R I L I EI I 1 121 3I 6208 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />