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IWaste Tire Sup .ey & Inspection Repor , Inspection Report Number ■ <br /> "' State of <br /> 81California <br /> (New 04104) I 1 - 1127668 <br /> California Integrated Waste Management Board Survey Form - Page - - - - <br /> Part A- Survey_ - _ __ ___ <br /> — <br /> BLUE R BLACKINK <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: I, Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Sao �Q ��f� com A� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 I O �cn CSc of <br /> Av,, <br /> �(�H Inspection Date <br /> e- Time In Time Out <br /> Business Rep Title O AMO AM <br /> I 5 0 PM O ® PM <br /> � nssi <br /> ry� <br /> ------ — --- — �l --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IJ Active is Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> D 0 Inactive Truck <br /> Longitude — 0 Planned ® OTR <br /> 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> 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 O 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 I A l HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 m / m <br /> 0 0 114 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 FXT) <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/CIWMB Enforcement <br /> 0 0 114 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 Compliance - No Violations <br /> 0 0 Other: § <br /> CommentsD D A 1 1('�f�_ Q. Sal �D�- (A L)i _0 ow <br /> (Inspection Form Included:®'I I��,�, <br /> Comments Included. Di -_ °� �1 — ---(�` 'y % - - � <br /> Bust Re s SI nature Phone Number Inspect s Signature one Number <br /> INSTRUCTIONS ON BACK li Correct Incorrect: ' E XIA Tic 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />