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8227040121 <br /> Y & Ins ■ <br /> Waste Tire Survey o Inspection Report Number <br /> Inspection Re P <br /> State of California <br /> Surve Form - Page 1 I1 - 1088389 <br /> CIwM9 7e,(New ge Y <br /> Callfomla Integrated Waste Management eaard <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � i 2 a Inspection Type (Fill one) <br /> Site Suffix: 110191-1-11 J [ S O ®Routine Q Re-inspection Q Referral Q Observation <br /> j <br /> LocalT If Referral,choose referral type(Fill one) <br /> Identifier: ( ane Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _t i1 Inspected By Inspector <br /> S-roc l�in�y Ih �,)'YIa 1 <br /> Physical Address f- f J I q - M10 <br /> 3DB U - -1— CiK I L <br /> Strasf I <br /> L ^, C n — ^ �,Sa'a I Inspection Date O / 3 O J / <br /> fy ��J 17Iv, ,Ilii-�f;�U1�C_' l(.J:y"t1- Sta'e ZIP ode Time <br /> In __ Time Out _ <br /> Business Rep 1� Title 1 0 AM 1 T i� Q AM <br /> x4j��ffAA Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler (D Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 /> Q Used Tire Dealer Q Auto Body (a Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j-1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-9 -Responsible <br /> E in Vehicle m m m <br /> Q Q 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred l 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 /> Q 1 Q Other: §` �) / f '(,� <br /> Comments n,, {,�_ I�.S `f/- (cl$J•, l�D�C$ ,J�l! �y o (/t t� e <br /> l fCb�'tM�vtx *OWCk L � �ri ��e_Q W18t'l�(yl raw 1 <br /> n st#V Jw <br /> a <br /> Inspection Form Included: <br /> Comments Included: _ <br /> &b VI L� 0177-2a9 <br /> Business Rep's Signature Phone Number. Inspecto s Signature � Phone Number <br /> �( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:�� NJ 0 X A M P LIE[ 1112131 <br /> ■ -White Copy CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />