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Waste Tire Surae & Inspection Repo"Inspection Report Number <br /> Y p <br /> I California <br /> New04/04) Su rve Form Page 1 Il - 1143801 <br /> California Integrated Waste Management Board Y - J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q � Inspection Type (Fill one) <br /> ® � <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Locala-- If Referral,choose referral type(Fill one) <br /> Identifier: Sal" v G 1.6 r\ Cou- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> U Inspected By Inspector <br /> An-,ma Co <br /> C.v J 3 q - l 0 <br /> Physical Address 5 <br /> SID"0[N 9S ao(D Inspection Date a <br /> '[ Time In Time Out v <br /> Business Rep Title y,tt C� 00 AM I O AM <br /> 1 t ` J CPM QPM <br /> Luo A (Q-ve-s _TVwS. m - - -- <br /> - - -- — - --- - - Operational Status Tire Type I 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 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered NJA <br /> GPS Latitude 0 Hauler 0 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 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 WT Orl ,t4tr <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityLENF0RCEMENT STATUS <br /> V 1 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 <br /> m <br /> 0 1 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <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 1 i <br /> 1..t7 I <br /> �I` ---- <br /> Nok� . I. Fac.��.►� W��San � r ; �. Setv�� �� des Inspection Form Form Includ : 0' �1 (� Q r►Q <br /> Comments Inclu ed: 0 -- ---�J� V <br /> Busine Rep's Si ature Phone Number Inspe is Signature Phone Number J <br /> - -- _ <br /> INSTRUCTIO SON K Correct: Incorrect: X A M 1 2 3 62081 <br /> X � - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop LE <br />