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Waste Tire S,U. .ey & Inspection Repos. Inspection Report Number ■ <br /> �r t State of California 11 - 1143732 <br /> CIWMB 181( e <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> PartA- Survey___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I t-� - Inspection Type (Fill one) <br /> Site Suffix: I (D Routine Q Re-inspection Q Referral Q Observation <br /> Local r'^ If Referral,choose referral type(Fill one) <br /> Identifier: <br /> S p�.n J00 tt C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> y O coSkCD � <br /> Physical Address 1 J 1T5 ES�p <br /> C^ ����� Inspection Date <br /> A <br /> 1 , (1��Ca� H <br /> Time In Time Out <br /> Business Rep Title � 0 � . u 0 AM <br /> PM <br /> 3 ' U ® PM <br /> -- ----- --- — - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 40 Active S Passenger do Generator Q Outdoor <br /> GPS <br /> Latitude Q Closed Q Altered Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> 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 /> I Q Notice Of 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-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 /> 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 <br /> i In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments KAJ�IIT1\� W4-It. t't PA UIQ <br /> No �jl' alo-6on or <br /> Ilnspection Form Included: OI <br /> Comments Included: ® "O -'77_�1't/1_... C•�`'-IJ <br /> i s�Rep's Signature Phone Number Inspe�r'sSiqnaturFe Phone Number j <br /> INSTRUCTIONS ON BACK Correct.* Incorrect: N/ V �X A M P Ir �; 11, 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />