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Waste Tire Su . & Inspection Reportispection Report Number <br /> 6�aR3:GE State of California N--- <br /> CIWMB 181( e ) Survey Form Form - Page 1 11 - 1088398 <br /> California Integrated WasttManagement <br /> Waste Management Board J g - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile! Inspection Details <br /> TPID- J � ' r r I + l I Inspection Type (Fill one) <br /> Site Suffix: L (•'I r ! ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: '�u� t .,/,Ci,��t �1(� :� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> p y Inspector <br /> Physical Address .? /TTC <br /> j C <br /> LWIC di-t <br /> Street 46-d [6 <br /> r^� Inspection Date <br /> Clf+' State Zip Code Time In Time Out <br /> Business <br /> Rep Title / 0AM ` Q AM <br /> 0 PM <br /> 0 PM <br /> mimOperational Status Business RoleStt>rage Tym <br /> „ ��; (Fill one only) (Fill all that apply) ;(Fill all that appfy• <br /> u, Generator Odoofrr� <br /> _ v <br /> r <br /> Latitude Closed <br /> GPS <br /> 0 HaulerAr <br /> �-Indoor <br /> Longitude 0 Planned , 0 End-Use Container <br /> Business Type (Fill' <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ® 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 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 'PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -.: - - - <br /> 0 0 ' 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 1 fr<(. <br /> J_ , - _i 1 t� 1,d 1Gi', ��-�-�- :� = - ��( �"..E l Vi a f �1✓OL I f� �ir:1 <br /> 1�' — _%'d1 "d\E'.�Y,i/f � s`"� � -�:f�( t�, .( -% fG Y1 vi ;✓i (`'{s-� / f t- 7- <br /> Jc'f Jf j ce f occ rpt. ,, 1 r% ON <br /> y�i(),;Cc✓ . <br /> YV?CI irl {v_1c scni� i/� fft i� Vt�l,fCt �(r rlJ` � <br /> �,,. r%,;r�'��r"7 ,N�, <br /> .�""',l^✓f'"r�f ~ �"'3^" ""„„7�,"' k f "d'r"•�• A'vdrsn�myG,'ra'a"yry' "/yry� �r� +ra: <br /> Inspection Form lnc(uded 01 <br /> i <br /> I�usinessReps= ignature <br /> PTione Nu <br /> Comments Included: y <br /> -- --- <br /> p g Phone Number <br /> • .: _.. <br /> INSTRUCTIONS ON BACK -Copreot-- Incorrect: X ,a 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />