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Waste Tire SG•✓ey & Inspection Repo Inspection Report Number ■ <br /> State of California <br /> California CIWMB 181 t eM a age Survey Form - Page 1 Il - 1088022 <br /> California Integrated Waste Management Board J <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- a^� Inspection Type (Fill one) <br /> Site Suffix: _ O d Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type Fill one) <br /> Identifier: <br /> �Qrl n Coo 0 CHP 0 CIWMB 0 Complaint0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Ins pe B <br /> p Y Inspector <br /> � m TranS�or —znc., <br /> Physical dress <br /> Street <br /> �reneh Cam / q�.23 I Inspection Date <br /> _ 1. 1 <br /> _iate .T-_I Time In Time Out <br /> (�ii,/ �_ Slate :�'1PCode [ _.. —.-. [_]—]0 AM <br /> 0 AM <br /> Business Rep Title 0 PM - � � O PM <br /> Operational Status Tire T ' <br /> p Type Business RoleStorageType <br /> ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)', <br /> ® Active 0 Passenger (2 Generator 6 Outdoor <br /> 10 <br /> Latitude <br /> 0 Closed 0 Altered <br /> GPS . — -_� 0 Hauler 0 Indoor <br /> Longitude - 10 <br /> 0 Inactive 0 Truck <br /> 0 Planned 0 O T R 0 End-Use 'Container, <br /> f Business Type (Fill all that apply)Y — — -- - _ <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 /> — -- <br /> V 11 A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / IE <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 0 Other: § <br /> Commentsu� 41__ <br /> -:-�.. �15 +�_C�� '�"r lsc. �011 OI.UI (1 W`tS o <br /> ro'X_. lib Wcste �-+res ore orn—Sv, e e ► ries_ -T ` <br /> ire >11trI bu�on <br /> ,.� to use 'hre� r t m ov ckl . C7,1- rr�n �,,�(E As .� <br /> )J,�,, tae +_ -4 0og, G-ef <br /> r <br /> a e a c c) <br /> Inspection Form Included r t ^ <br /> ✓ r <br /> p& � <br /> Comments Pncludeci. 0 aSig' <br /> Business Rep's Signature Phone.Number'""' tnsg�6o ,_'snature ✓ Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ` n "X A M" 1_�� ' j �� 3 62081 <br /> e . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />