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-= Waste Tire QWy & Inspection Rep" Inspection Report Number ■ <br /> frS — <br /> State of California I 1 1127735 <br /> CIWMB a.'eManage) 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- l ++ Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: — Sc�n �C LAY�- 6'juyt 0 CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> t\U , ��h 'S1e�11 7YlG, qr--- /� <br /> Physical AdIci ess l ' l - (J TT �7�J7 UCS A a <br /> rnUq <br /> 3 11q Zc� �� '1 <br /> 0 C- — <br /> Inspection Date ) L 7 <br /> tv(A--r-n Cts a�:�U� C vv <br /> Time In Time Out <br /> Business Rep Title G� O AM I O AM <br /> �'Tf�F�IEi r 1�l��f(�'?"1Ct✓1 ,i ' ✓1n�C✓�'f �`�� � � G ®'PM � � �l �--® PM <br /> ` --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' '—] 4� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> e ®Active ® Passenger ® Generator 40 Outdoor <br /> _-- - -- ----- - D Q Closed 0 Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — 0 Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder ® Other � � J�� �mfjlV <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 /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 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 /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 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 /> Other: § <br /> Comments <br /> 04/06J A ev6 126 <br /> ZL� <br /> Inspection Form Included: Q <br /> Comments Included: Qi- — <br /> __ 205-9/14//. /01 -- rG- Y�� ---- <br /> Usines 's Signature Phone Number s e g ture Phone Number <br /> INSTRUCTIONS ON BACK Correct.0 incorrect X <br /> I 62081 <br /> ■ White------------------- ® ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink CVK <br />