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is Waste Tire Sur%y & Inspection Report Inspection Report Number <br /> 1, <br /> State B California Il - 1140998 <br /> Cgrated 1 teManage 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- ' rJ _ �. Inspection Type (Fill one) <br /> Site Suffix: O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _ �� Yv [� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name —- - <br /> 2 Inspected By Inspector <br /> �JC IG. �tx GCS f�]r� r cue �� - C � ✓�►"e(,.J <br /> Physical Address / � 0 <br /> a LlV ask - <br /> Inspection Date 0 Cj / Z 0 / f <br /> Time In Time Out <br /> Bu iness Rep Title V 9d J`I 0 0 a Q AM 3 `j Q AM <br /> 'Y' <br /> Oil <br /> ® PM ® PM <br /> r� - <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> - ° 0 Active ® Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GrpS Latitude 0 Hauler CHndcri <br /> 0 0 Inactive Q Truck <br /> Longitude - — 0 End-Use Q Container <br /> 0 Planned ® OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Mir�cTr C-Es Q.CC Y A st-g-S <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A ;HAULING AND MANIFEST REQUIREMENTS <br /> --------� _...---._....___�--------- <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 m / m / m <br /> 0 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 /> 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 �IJ <br /> Wl� aYXF1l1 SAN Ko -i TN.i 5 Its., <br /> Inspection Form Included: 0 <br /> Comments Included: �inesp4'��Si�at, <br /> r one Number ector's Sign re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Ctlrrelt.,�r Incorrect: X �, ,k� X �l PIM <br /> I. <br /> White Cop :CI JB Yellow Copy:Operator Pink C y:L <br />