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Waste Tire Su. . Jy & Inspection Report inspection Report Number ■ <br /> F®.Q State of California <br /> CIWMB <br /> grated 7(New04104) Survey Form - Page 1 Il - 1143990 <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: ' ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �X,�1(� ��{(✓�( (/ (:JC/�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ?� _ <br /> Physical Address 9 <br /> 1610 Ave- -- <br /> I <br /> jv _ /f� �ry� Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM AM <br /> �J rt� O ' J 0 O PM V O PM <br /> C�Ct�{—Il 1 r_C__;7.1C_�_ c� 'rci ��-�vis— _ ---- -- --— — ---- -_ _g -- <br /> --- — Operational Status Tire Type I Business Role Storae Type <br /> Fill one only) Fill all that apply) FIII all that apply) (Fill all that a I <br /> Tire Count(Whole/PTE) /� ( ( pp y) ( pp y) <br /> C1 0 Active 0 Passenger 0 Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 46 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 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 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 /> LI1. <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 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 <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 EXT) <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 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 Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> �l L4✓ CL.P-I - - - r_il <br /> Inspection Form Included: 01' pp QQ <br /> Comments Included: ®I <br /> usin s Rep's Signature Phone Number n cto Signature Phone Number <br /> - - <br /> INSTRUCTIONS ON BACK Correct:D Incorrect k A- ¢t O✓ 1 7 � e t� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />