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091 $2050075 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> ClWMB Waste <br /> nage Survey Form - Page 1 12 - 1 0 7 9 3 3 2 . <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G� /n � Inspection Type (Fill one) <br /> Site Suffix: O I `� / / ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier; SQ lt✓ oQ _ _ _ _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit .0 Other <br /> Business or Facility Name U Inspected By Inspector <br /> RdQ-.o cz_ E_x� I <br /> Physical Address <br /> Street'(\�71�-) 957 <br /> U <br /> I v " �'Vh y v ' �� I Inspection Date <br /> City Stale ZIP Code Time In Time Out <br /> Business Rep Title AM AM <br /> [jR] <br /> D V 0 PM � � � � ® PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> Tire Count(W hole/PTE) ; ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> 0 Active 0 Passenger 0.Generator 0 Outdoor <br /> 0 0Closed 0 Altered <br /> GPS Latitude I—� I • I--- -I- I I t� Hauler ® Indoor <br /> — <br /> J 0 Inactive ®Truck <br /> Longitude - I-- I -I- I100Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) JJJ <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 t I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility . ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 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 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 /> 0 Other: § <br /> Comments RP�i (k _�Q 1( Aale 1�10�t°5 � fD1/�rie- <br /> �,�Q,S�2 tll(es GjQ1'e <br /> cCe��oo SecE DF ' ire2 s a o�o, r open a,#a�'_ T�h ft�cZt71-e S S fD✓c� cit sz1e <br /> _�VY 5PC Xrfs. e Ism 1'0_t4`fie i s o�_st k avian occa sic hd on-si� ✓egdtor fv-r <br /> �i1'2 SerViC,,Af � f-/�5-_ Ldn 0 n �O�J� Cc(,� Crus 1 h5-�tiG� f0 <br /> Inspection Form Included: 0 <br /> Comments Included: ® —&`n L <br /> Business Rep's _ ature Phone Number Inspecto s Signature Phone Number <br /> INSTRUCTIONS ON BACK Co recta ncorrect: X I t 62081 <br /> ExAMP 'L E 1 2 3 <br /> White Cop :CIWM Yellow Copy.Operator Pink Copy.LEA <br />