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■ t'Ej, Waste Tire Su, .;y & Inspection Report Inspection Report Number <br /> State of California <br /> Cgrated 1st(New <br /> Manag ) Survey Form - Page 1 Il - 1140893 <br /> California Integrated Waste Management Board <br /> Part_A_Survey_ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S — b ( Inspection Type (Fill one) <br /> Site Suffix: V ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: yyt u 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name T V Inspected By Inspector <br /> �vl►�cP.t k)C,c 6 - c . j O , p <br /> Physical Address � � _ ` / �y;►;yL'GYt��c DL^�'il� <br /> vzcl <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> ^��GE ` G PM V v� O ® PM <br /> t' !vGr� Tcy <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 /> 0 Active 0 Passenger J1 Generator • Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O 0 Inactive • 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 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 HAULING AND MANIFEST REQUIREMENTS Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 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 /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Other: § <br /> Comments <br /> JdA JfH rtTreit 1 , Z�aC17� — <br /> 1a/�cC dt0k�[ = --- <br /> !Inspection Form Included: 0 X <br /> Comments Included- 0 <br /> Busin ss Rep's ignat re Pho umber nspectoes Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: ncorrec : ( ¢ 62081 <br /> White Copy:CIWMB Yellow Copy:Operator ��Pink Cop <br />