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Inspection Report Number <br /> Waste Tire Su ey & Inspection Report <br /> State B California Il - 1141329 <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- Inspection Type (Fill one) <br /> © <br /> Site Suffix: ` 0 Routine 40 Re-inspection 0 Referral 0 Observation <br /> LocalJ If Referral,choose referral type(Fill one) <br /> Identifier: S(A� �U lJ of n (044 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name "_, Inspected By Inspector <br /> O n <br /> Physical Address FS/,,�-0 <br /> �%qn <br /> - ko Inspection Date ( V / 07 <br /> / 0 <br /> CTime In l V Time Out/ <br /> Business Rep Title O AM 0 AM <br /> m 3 dr PM 0 S a PM <br /> Operational Status Tire 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 /> *Active 0 Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned • OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) Vt� <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Other L)4 S�-r V)t(t5) S��S)f gct,r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ <br /> -- 0 Notice of Violation 0 Extension <br /> 0 0 <br /> 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 M / m / m <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 Ze /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 liance - No Violations <br /> 0 0 Other: § <br /> Comments �� 1 f)i i n �Vt(jLdr\ 1 �1-V1(� <br /> 9 �� '. <br /> Inspection Form Included: 0 � - 117 9 <br /> Comments Included: 0 <br /> B Hess R p'sf Signature. Phone Number- Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Corre ncorrect: �/ E,X A MIS P LIE! I Z 3 62081 <br /> While Copy:CI M Yellow Copy:Operator Pink Copy:LEA <br />