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Ins eWaste Tire Survey & Inspection Report pes n 3 0�oo�a <br /> ie_ ctioReport Number <br /> ,�, <br /> Stateof81(NmW I1 - 1108492 <br /> cgrated ,(Now 04/04) Survey Form - Page 1 <br /> Califomla integrated Waste Management Board <br /> Part A. Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> Site - r1 � 10E <br /> Inspection Type (Fill one) <br /> Site Suffix: ` I fl Q Routine Q Re-inspection Q Referral Q Observation <br /> Local r 1 If Referral,choose referral type(Fill one) <br /> Identifier: San1o_M11.0Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I <br /> Business or Facility Name Inspected By Inspector <br /> Ph�ysl I Address I — Q <br /> 3 1 <br /> L&odyA- <br /> ----j <br /> Strset <br /> 1 103 Inspection Date I U I� ,'a / <br /> CiL-1✓ C�tote 11 ZIP Cod Time In �J Time Out LLL��� III I <br /> Y <br /> Business Rep TitleN oQE2 �— 0 AM .h—; �I� 0 AM <br /> J <br /> 6 13� <br /> -- <br /> WAK) --- ' �-cwuM 0 PM PMS _ _�, ----- — - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f y (Fill one only) (Fill all that-apply) (Fill all that apply) (Fill all that apply) <br /> ActiveQ Passenger ®Generator Q Outdoor <br /> O Q Closed <br /> GPS Latitude Q Altered Hauler Q Indoor N/ <br /> --_O Q Inactive e 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 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber ^ p <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 46 Other LUI ._(amu-11 v I <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STAT S <br /> MINAU1HAULING AND MANIFEST REQUIREMENTS Q Notice Pont Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956- <br /> Registr Vehicle <br /> Q Q14 CCR§18459 -Responsible Entities m m <br /> Complying with Manifesting Requirements <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 ( equrred 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/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 10 1 Other: § <br /> Comments <br /> 5 <br /> �i�'c,=�_�aca�� t�Yi.S��,cx��e._�o uu_�--�if�o-r�Qs� �__��-_��, • <br /> Inspection Form Included: Q �OkLs - ,- <br /> Comments Included: <br /> E6ssinere Phone Number Inspe ores ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C•o ect I correct:correct: ]EIXIAIMIPILIE1 1112 3 <br /> White C y.CIW Yellow Copy:Operator Pink Copy.LFA <br />