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<br /> ,yf tins Rsection Report Number Tire Suy
<br /> State of 0
<br /> California Integrated WCWMB aste Managernedt Board Survey Form - Page 1 -, 10- 2 5 .,6 9
<br /> �PrtA Surve BLUE OR BLACK INK PEN
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<br /> Slte Sufflx: �'Routine 0 Re-inspection 0 Referral 0 Observation
<br /> a. Local _ If Referral,choose referral type(Fill one)
<br /> Identifier: :rr's (JC%+ (,�, 1('�Lt r'� f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> , � IL hC
<br /> Ph sical AddressT/ 0
<br /> 00
<br /> Street Jt�
<br /> %+ Inspection Date ) / / EE I1, c� . � 0� , FJ_A7
<br /> City State ZIP P`ode Time In Time Out
<br /> Business Rep Title / y O AM Q AM
<br /> t ���� (�^;�' L `!j �/ ! r E! �'� ��✓,( i %j� � �._1_ O PM QPM
<br /> r r�y01F M "'n'"j/t'�a:i �+.ti '�Y i �,„a,P'"r z �y Trr ,yaw n .,;r ,.,,, ;.t, F wz,/,,.taa u.,i,r, .;N d✓"" ,, W %wrr.. S ar r M a �Operational Status Tire' ypel' Business Role a
<br /> (Fill one only) (Fill all that apply)' ('Fill all that apply)
<br /> 6'4 �l tirftur A rr, r r;
<br /> L/ (fif Active 0 Passenger eT,�w' Generator rl��bor
<br /> O 0 Closed Altered
<br /> GPS Latitude � ' a,:- w," 0 Hauler 0 indoor
<br /> F -t
<br /> - 7 -1 0 0 Inactive 0 Truck
<br /> Longitude - 0 Planned 0 OTR 0 End-Use � Container
<br /> Business Type (Ril 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 ( 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. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 0 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 /> Comments r 4J, p- 4,d al 1 t)ye /Iy1kti'A I-C; �
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<br /> ( 1 Et. /It 0 jt' a the, 1-t�.,
<br /> f Cet'(f a� y �jGrf G� � it U GI'I (yY `'� f` �t�� -�,_tet� r� `- _,_
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<br /> Inspection Form InClUded4:PS;n3 "dwt
<br /> �""",'�wc '�v it "a" •tic "r. .
<br /> • cG
<br /> Comments Included. 0
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> _ 62081
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X jl�, A �'t
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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