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09203050042 <br /> WHE Waste Tire Survey & Inspection Report Inspection Report Number <br /> fl State 01181(Now <br /> T ,e O^ ^O <br /> grated l(teMana a) Survey Form - Page 1. � 11 1 8 �9 UVJ <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: ` 510�1 noll ® Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (, J0 uln �{1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name Inspected By Inspector <br /> CASPhysical ress � Ley,,�_r, "((I•� J <br /> (—��V�--!�-1-oJ•1-r(,!��• I 111 ete...JJJCCC...///---JJJ �jJ(((,,,000��'� <br /> rA <br /> Street <br /> 1,,_A <br /> Q �'' n Inspection Date <br /> L � - -Q1�1 Time In Time Out <br /> City sf8te ZIP Coot <br /> Business Rep TitleI� <br /> - q 0AM � ®AM <br /> 0 AM l 1 PM <br /> Operational Status Tire <br /> _ p Type Business Role Storage Type <br /> Tire Count(Whole/PTE) . (Fill one only) ' . (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r 3 60 Active to Passenger Generator IIs Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> ---- - -- -- - -- 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 0-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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Not' a 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 Dea t'ne <br /> Q Q PRC§42956-Registration/Decal in Vehicle <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 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 /> In Compliance - No Violations <br /> Q 1 Q 1 Other: § `` {� <br /> — <br /> Comment; -6 X11 M M —On ��-1— IS�, Q,-C AA 1 1-0-41 <br /> C/= 1 <br /> WW►`o�1S 6S—W,c u� <br /> Inspection FormIncluded: Q L , <br /> Comments Included: 0W— <br /> Busin s Rep's nature./ Phone Number ins dors Signature Phone Number, . <br /> INSTRUCTIONS ON BACK o ret: E X A M P .L 1 2 3 62081 <br /> ne�rrct <br /> White Cop .CI Yellow Copy.Operator Pink Copy.LEA <br />