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09210040500 <br /> 6HA Waste Tire Survey & Inspection Report inspection Report Number <br /> 1B State of California <br /> CIWMB 7f11(New04l04) <br /> Survey Form - Page 1 L - 1108491 _ <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 /> Site Suffix: 5 0 0 [Clul <br /> Routine Q Re inspection Q Referral Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB (D Complaint Q Educational Visit Q Other <br /> Business or Facility Name UlJ ` 4 ` Inspected B <br /> P y Inspector <br /> S I 1 mac, 7f-L)C, Ivy <br /> Physical Address11 <br /> Street E141 <br /> Inspection Date <br /> �.np �n q <br /> L _ i1c.L— "m � `—J Time In Time Out <br /> Crty State ZIP Gode <br /> Business Rep Title 0 AM Q AM <br /> V '�V150Y <br /> Eli] <br /> ® PM 3O0 PM <br /> Operational Status Tire Type . Business Role Storage Type <br /> i (Fill one-only) (Fill all that apply) (Fill all that apply) (Fill all-that apply) <br /> Tire Count(WholelPTE) I l <br /> s <br /> - ® Active Q Passenger ®Generator ® Outdoor <br /> O <br /> GPS Latitude i i Q Closed Q Altered <br /> • i— - _ I j � Q Hauler Q Indoor <br /> Q Inactive 10 Truck <br /> 1 JIO <br /> LongitudeQ Planned Q OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V qHAULING AND MANIFEST REQUIREMENTS <br /> Q .Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extensio <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required torNOV or <br /> Q j 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q I Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Re erred/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 In compliance - No Violations <br /> 100 1 Other: § <br /> Comments <br /> Inspection Form Included: Q 57- <br /> G <br /> Comments Included: Q L 2 0/— ( P2 _///C <br /> Business Rep's.Si re Phone Number Ins c rs i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr ct: correct: E XjAji1li LJEJ I1 2 3 <br /> White Copy:tIW Yellow Copy.Operator Pink Copy:LEA <br />