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Mjj WasteTire Su. /ey & Inspection Repor'� Inspection Report Number MState CIWMB California I 1 - 114 3 7 61 <br /> grated Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part.A-_Survey _-- _ _ __- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � I Inspection Type (Fill one) <br /> t'' <br /> Site Suffix: O 0 l O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localr"' 1 r If Referral,choose referral type(Fill one) <br /> Identifier: Cru n� <br /> S �n J OQQ�t n � 'Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Co_ <br /> Physical Address I y 3 0 Cn 1�C <br /> 5� <br /> \a,1 N , <br /> Inspection Date 3 5 / 10 <br /> Time In Time Out <br /> Business Rep 1 Title 0 O AM Q AM <br /> o� V O i� PM O ® PM <br /> -- -- - - --- - -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3- 4D Active 9 Passenger li Generator fj Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q PlannedOTR End-Use Container <br /> Business Type (Fill all that apply) <br /> i , New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ' Hauler Q Agriculture Q Shredder Q Other <br /> f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT-STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> QQ 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 <br /> M / m m <br /> Q Q 114 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> i <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive 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 114 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q I Other: § ] l_' - <br /> Comments (1lL 10-804i b s� (9n71 )n\S A t Cl { kt0W� n_o ? <br /> —I_i-riI'�t'ICSOn (AAA4, .0-- Corlto rf1-- -- - - ----- <br /> I <br /> insection Form Included: <br /> �jy p Comments Included: 6 - J6 Cam) <br /> Busines ep' i na!re Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect I _ ("E X 1 i 62081 <br /> C:=�� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:L ® ■ <br />