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Waste Tire Su ?y & Inspection Report Inspection Report Number ■ <br /> State of California <br /> ss is <br /> CWMB 1st(New <br /> Manag) Survey Form - Page 1 I 1 - 1140670 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 0 S J _ © Inspection Type (Fill one) <br /> Site Suffix: o 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �Cuyl DACµt-n C_`,, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> I Business or Facility Name U J Inspected By Inspector <br /> Physical Addr s 3 / — J / <br /> Ahr­,c,�, J�oy+; c,,ti <br /> I(0 2 $ r2,0�xX�50 n Dr. <br /> Inspection Date 0 y It <br /> 3 oY <br /> Time In Time Out <br /> Business Rep Titlen �7 0 AM (/ 0 AM <br /> 0 0` oG ® PM O 'Z Y S ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 95 (Fill one only) i (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 /> ® <br /> Latitude Closed 0 Altered <br /> Gp� <br /> - 0 Hauler Indoor --- <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 ® 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 /> _ 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 /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> 0 I 0 § 9 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 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 /> Comments <br /> r }t -1/i S i "1'` 1 &A-5- Q Ccs I[l =f Yla— C7i�_U�l, <br /> GKC 1 i 4 ) Vlt,<< G�,Sccl. t►9-4Ayj_c�1��e-�rvc -cz ts�It l car l <br /> V kuct_� -, cA o e,�S _to c-Ae-Q i2e c oyny ,e-� 4-0 C-US-e I <br /> Inspection Form Included: 0 <br /> cl�S`c 3 <br /> Comments Included: 0 - ------- -- -- - - `�` <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> � 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. . EX A M P (� 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />