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18 Waste Tire Sur . _y & Inspection Report Ispection Report Number <br /> ii State B California I 1 1140874 <br /> Cgrated Waste <br /> eManag) 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- 4 � a t _ Inspection Type (Fill one) <br /> 4 4 .1 <br /> Site Suffix: <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: eve, L� V— CCf1L4-1,N_ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - - <br /> Business or Facility Name Inspected By Inspector <br /> k S CYN `J i x Q►`� �t�C L'YY1(JG CG1Sd C /,__ / <br /> Physical Address - 0 <br /> 7 3b IA�Okrd Ale_ <br /> Inspection Date <br /> S�c_.,rc tv� C� �.��!S <br /> Time In Time Out <br /> Businepsk Rep TitlQ AM 0 AM <br /> © I 0 d ® PM U - S ® PM li <br /> Operational Status li Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O ' ® Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR j 0 End-Use 0 Container <br /> Business Type-(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair *Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS 1 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers li 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 01 0 Other: § <br /> Comments <br /> _ aaU 7 Yze, <br /> IvLcr <br /> Inspection Form Included: 0 <br /> Comments Inclu - -- - -- - -- - <br /> ness Rep's Sign re Phone Number Inspector's Signatur Phone Number <br /> - - .. - - -- -- <br /> INSTRUCTIONS ON BACK !Cdrncnrrecfi ) ' N! rX ,q°, y 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: A <br />