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Waste Tire Su, y & Inspection Report nspection Report Number <br /> '•Stdd State B California I 1 - 1141019 <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 /> Site Suffix: j 4 S { ( 0 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� � r C, {� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l+ •l Inspected By Inspector <br /> Pe� ff-,)a rA 3 <br /> Physical Address �k►^^GMG>10. l� r+�e <br /> A 5330 Inspection Date Q / 2 2 / O <br /> I C Time In Time Out <br /> Business Rep Title ® AM _ 9 AM <br /> 0 0 QPM ' 3 OPM <br /> Gfec� 5 .1 nvcv�kt �I - - ---- <br /> -- �J -- - - O eration Status Tire Type Business Role Storage Type <br /> P YP <br /> Tire Count (Whole/PTE) Fill one only) Fill all that apply): (Fill all that apply) (Fill all that apply) <br /> f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> C 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 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 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other Pe- 'QJ VW_tA,,t,Lf-a&LWy�p <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS J <br /> V 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 / 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 f 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 1�d <br /> Inspection Form Included: 0 <br /> 6,70 el) y&?—06 z <br /> Comments Included: ®, e ' -- <br /> Business Rs Signature Phone Number nspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Xi X A 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: E <br />