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Waste Tire 40ey & Inspection Rep" Inspection Report Number ■ <br /> ,aIle State CIWMB California I 1 - 112 7 7 2 0 <br /> ��� grated 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- Ll O - © I Inspection Type (Fill one) <br /> Site <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local )n �Uu�] If Referral,choose referral type(Fill one) <br /> Identifier: S(�� JO {u l ' 1 � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (` 1 6 Inspected By Inspector <br /> � <br /> 3c)�k M &��,C 6VA US i f) I f <br /> Physical Address 3 9 - C� 1 �� Gzl,C 1p <br /> ��:)-o k ��o f M tL�)L(Z- <br /> Inspection Date P <br /> Time In 111 Time Out <br /> Business Rep Title O AM I 0 AM <br /> r � ® <br /> Jon Woodall � PM P <br /> - --- - - -M-- <br /> - - - ---v 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 /> Active 0 Passenger ® Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned ® OTR - End-Use —1 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 mM <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 1 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: § l^ al..- <br /> l I <br /> Comments 101 \L1R�_C15�L rt1 OS _ Qn Y 1� T�_ �Y19� `QLt�7777O <br /> c15 n C � <br /> t "` <br /> -nU V!0 clI o� C71(c< <br /> S 6�-- uS o� conc !(1-< . - - - - --- - -- -- -- -- <br /> �j�L'• �. �uC14;k _��c�-�-��,�nwu.V ��' Tru,c.�L.-��f��!'Vic��- Ul��+��r �t j��j�.5�'VI�C�� <br /> Inspection Form Included: 0 <br /> - y-air_A0) <br /> Comments Included: O?BIne <br /> ss e s Signature Phone Number Inspe or's SignaPhone Number <br /> -INSTRUCTIONS ONK Correct Incorrect X A � 11213 <br /> 62081 <br /> ■ WhiteCo--- — — — — ® ■ <br /> py:CIWMB Yellow Copy:Operator Pink opy:L <br />