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Waste Tire Sr rey & Inspection Repor ' Inspection Report Number <br /> State of <br /> Survey Form - Page 1 Il - 1143783 <br /> california Integrated Waste Management Board Y �J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: — ` q fZ - © l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local t \�J��� \ If Referral,choose referral type(Fill one) <br /> Identifier: X_X it �r , 49u <br /> � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ,r <br /> Physical Address <br /> 153 '_ /`pct,r j�i -t- Y►� <br /> Inspection Date me ut <br /> 0 <br /> c4, �� � Time In TiO <br /> Business Rep Title O AM O AM <br /> O Q ®PM a PM <br /> — - - - --- Operational Status Tire Type li Business Role Storage Type <br /> Tire Count(Whole/PTE) A 5 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V 0 Active IS Passenger * Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ffl / M / M <br /> Q 0 14 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 /> Q 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 !i 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 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 <br /> Q 0 Other: § (I In Compliance - No Violations - ' <br /> Comments <br /> IInsp ection Form Included: <br /> Comments Included. <br /> sineep's Signature Phone Number In a is g tur Phone Number <br /> INSTRUCTIONS ON B K Correct: Incorrect /) E X A LI t 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co ® ■ <br />