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== Waste Tire SL*ey & Inspection Repor Inspection Report Number <br /> PP <br /> 5��°`Cal"°`°� I 1 1088487 <br /> Cgrated 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- Inspection Type (Fill one) <br /> Site Suffix: L I 3 15 1 0 1 ; Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC�� � �1 nn� --, If Referral,choose referral type(Fill one) <br /> Identifier: J q l,1 `1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> BLus�n orFacilityFac�NameA rn i i Inspected By Inspector <br /> Physical Address y 3 I , LLOIAJ �I�n <br /> LLL--- •�. <br /> Street <br /> Inspection Date <br /> Crib 1 SStta e 'ZiiiPPP Ccde Time In _ Time Out _ <br /> Business Rep ^_,, Title O AM ---i • i0 iO i Q AM <br /> Doo rQn 1�W� ,�CC51 I • , -• PM — -�_ _ • PM <br /> - - -- -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) R (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that-apply) <br /> 6 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 41 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice iolation <br /> Of Q Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 F_XT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/C-IWMB 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 ® In C-ompliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments ���\-�!nS - !O�-�1►u-� I�- . -Q�"'l -�!�.W.i-(��J1/�W �yl�(�• • <br /> (>0 t 0� <br /> VVk )%.9 _cit esis_�C <br /> rp-- tl� <br /> Inspection Form Included: Q , 4%hone <br /> Comments Included: ® J -.JI r��Business Rep's Signatur Phone Number Ispe or'sSignature . Number <br /> INSTRUCTIONS ON BACKIEIXIAIMIPILIEI 1112 3 62081 <br /> White Cop .CIW Yellow Copy.Operator Pink Copy.LEA <br />