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Waste Tire Survey & inspection Report Inspection Report Number ■ <br /> State of California <br /> Cgrated Waste <br /> Survey Form - Page 1 1 6 . 1 0 2 5 8 9 2 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I � <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 1 1P Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � p I��1 C 0 Lt.Vc� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> , Inspected By Inspector <br /> 611 Park's Atd-D P fla.-i-e-/ <br /> Physical Address <br /> ShCk� �y n e��I� Inspection Date 103 <br /> I 1 <br /> (�Q r `(1J / Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> JI. l)4. � <br /> BOO // 1 O PM 0 PM <br /> � ,2 L{;1.11,{,�itG�G�, <br /> Operational Status, Tire Type ! Business Role Storage Type <br /> The Count{Whole/PTE) 3 5 (Fill one only) (Fill all that apply)' (Fill all that apply); (Fill all that apply) <br /> f f I&Active ® Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreador Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q 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 /> A HAULING AND MANIFEST REQUIREMENTS _- 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 /> iQ O .PRC§42956-Registration/Decal in Vehicle <br /> :0 ! O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Data m <br /> 0 . (* 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required IrorNOVorE)M <br /> Q Q !14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q R*%rred 1 CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® i 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �')p Gompllphcw - No Violations <br /> QQ Other: § -:.:_ .:::° ..-_'._....._..: ....._.—...... . <br /> Comments-Fa at 1'11 L Is wcas•r`e - re-s 11 a wler- b j J'6t cL I Ici_Tire _Di._)povd, mai,t, its Lcscd <br /> T ro✓►1 y/3 *t -prvs'4,&, !hVDiCes OF wCZSfie 7hre I-vti IS wQt�2 L<Sk.C- tx6, e 74tif' <br /> 'T-Pi3•# riot- wr^-* pi tm all vvianire,5fs . 1''ac,�Itf� •tag evisLcre hp/o#: wi i <br /> Wrf'irQ✓l ort Wacs4e Tire -rres Starecl betiim _f12P, of,�(`doo,- Sc,C1_4_1 <br /> Inspection Form Included: Q <br /> Comments Included: Q p olBu ss Re Sl nature Phone Number tor' nature Phone Number <br /> INSTRUCTIONS ON BACK 66iieat• 'Inco ( j'v- IL <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />