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_;. <br /> Waste Tire SIL ey & Inspection Repor Inspection Report Number <br /> State of California - i/''�� `///''''''���� n j��} <br /> California'Integrated fWaste 81 eManagement Board Survey Form - Page 1 I 10 10 0" 8 4 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5A�J �b � can,,K Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name —� <br /> �5 <br /> (,2Inspected By Inspector <br /> v�,1.��-� Ca(1,2��� <br /> Physical Address n e - V <br /> Zlo_�_o 10 S • � A N rA i2� STK <br /> Inspection Date � r„ / 2 <br /> /T UI ✓ l-I/ Time In rJ Time Out v <br /> Business Rep Title //�� Q AM Q AM <br /> DeiYi t 5 5r�(U4G JeA-T)11U 7�vhiAiA'1 (✓u,'tIL O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) or (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active O Passenger ! Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive 40 Truck <br /> Longitude - Q Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair 0 Trucking Fleet Q Government Q Retreader O Dismantler 0 Tire Derived Fuel <br /> Q.Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline _ <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / EE / 11:1 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> .1- -.- <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> Q Q 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 <br /> In Compliance <br /> 0 Q Other: § No.;;-Violations P . <br /> Comments g - - <br /> V , % �s02�.�i 7� art y r(�aL t itl_- ew%�ro1 Wow, <br /> 0 f_.�t� ..,� <br /> r <br /> Inspection Form Included: Q 2 <br /> Comments Included: Q �. <br /> 468 Tb <br /> ess Re s SI na re Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Incorrect:' X A M p L E 11127 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />