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Waste Tire Sui y & Inspection Report spection Report Number <br /> State B California I 1 - 1140966 <br /> Cgrated Waste <br /> 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- Inspection Type (Fill one) <br /> Site Suffix: 3 f r 9 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 7� N C 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> C, 6y 12 <br /> Physical Address <br /> 3330 N , Ari <br /> Cly K <br /> � Inspection Date� `J��IS <br /> Time In Time Out <br /> Business Rep Title Q AM / O AM <br /> f d2 0 PM © ` U 3 ® PM <br /> ,w►- /L�u rr -- ,moo '%ce•� ----- --- �— -- - - — -- -------- <br /> J -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f 5 %3 <br /> ® Active ® Passenger ® Generator Outdoor <br /> Latitude O Q Closed Q Altered <br /> -- --------- -- - — — <br /> O Q Inactive O Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 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 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § -/ <br /> Comments <br /> Inspection Form Included: O X v, <br /> Comments Included: ®' <br /> Busi s Rep's ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON ACK Correct: Incorrect: X , \/ f"_A L 1213 62081 <br /> White Capy:CI;NP.1 Yeliiiw Cuiry Opera!oi Fink opy <br />