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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> state of California 11 - 1088093 <br /> rniCR9Me t8eManag) Survey Form - Page 1 <br /> Caliloa Integratetl WastastManagement ement eoartl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ _ Inspection Type (Fill one) <br /> Site Suffix: ! 5 5 5 ( ®Routine Q Re-Inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: )�� <br /> ` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility NamAInspected By Inspector <br /> rA JalIe�,� P�aake,,tit�, ��nc . 3 cl - � ( /�l�►so �►ur►1b� <br /> Physical Address _n <br /> 15300 -S, <br /> rr"P <br /> Inspection Date <br /> �c1 �5��� ! C I <br /> Time In Time Out <br /> Business Rep Title 0 AM / Z O O AM <br /> l Z : 3 o wPM a PM <br /> ! V1 L <br /> Len►�C�rL� gl>t .C�C t� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �� l � (Fill one only) (Fillatithat appy) (Fill all that apply) (Fill all that apply) <br /> r L ®Active Q Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - Q End-Use Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Govemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQl11REMENTS Notice Of Violation U Extension <br /> v O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle FF1 fQ Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / j <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB III III <br /> / F <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 O Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Is In Compliance - No Violations <br /> Q Q Other. § <br /> comments Rol time_ lis -z,% 6y_-- cin, if S / &,J<_ avx1 -+h e 'tLI 111 I J4J <br /> �ci 4 e �• U 1 l`C lC�2��S OY ATea se C/Y (.-ance/ri <br /> Inspection Form Included: <br /> usiness Rep' ature �O phone Number�7 In ors SI�f re — - Phone Number <br /> Comments Included: I <br /> a <br /> ;Zud 1 <br /> ■ INSTRUCTIONS ON BACK Cor ect . correct:X EXAMPLE 1 2 3 ■ <br /> Pink Copy:LEA <br />