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Waste Tire Suoy & Inspection Report*_ nspection Report Number ■ <br /> n �4Q State of California <br /> CIWMB41(New 04/04) <br /> Survey Form - Page 1 i <br /> California Integrated Waste Management Board - ____-.._..10 f 3 6 2 3 <br /> Part A Survey BLUE OR BLACK INK PEN <br /> 1�flle Inspection Details <br /> ITPID- Inspection Type (Fill one) <br /> e Suffix <br /> �� v' Routine Q Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Fr�..f,.; i. -s' ; O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressI __j <br /> J-/ / + > f"J <br /> Street <br /> Inspection Date <br /> °/ <br /> r f� �.:i r '� ..� �...� <br /> State I Time In Time Out�' e Z!P Code __. , <br /> Business Rep Title r- / -� 'J.� � 0 AM <br /> PM t;� ^. Q O AM <br /> L✓�_ ® I � �~ PM <br /> I r:: r I - -- 77 <br /> Operational Status Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply)' <br /> Ifr� ® Active Generator 0 Outdoor <br /> GPS Latitude F- -1 0 Closed �Ah �'�)� tr,°r l <br /> t <br /> . � Hauler 0 Indoor <br /> — Q Inactive <br /> Longitude - - O Q Planned 0`OTR <br /> ,,7�t',r O End-Use O Container <br /> Gf � all that tiryS -,{Fillapply) <br /> Q New Tire Dealer O Auto Repair 0 Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Other <br /> - <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / FTI / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 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 ('` 1.1,; ("fir'.. :. n•: ,� ''�... frt- Y -'_.'! .-f' , er"' ✓, L-c J <br /> G� <br /> 7/4 /f.� zt /rfJ I C� _• '7/ ` c'.f �` /,. L // 7 J d <br /> i <br /> r.r- <br /> J <br /> J <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature_ _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: °✓� I:_ +, 04 P, L I�Y � � �� 62081 <br /> 'A' — <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> i'I <br />