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® L Waste Tire SL ey & Inspection Repor Inspection Report Number <br /> State of California - 1086963 CWMB <br /> 1(New Survey Form - Page 1 I 1 10 8 6 9 6 3 <br /> California Integrated Waste Management Board <br /> Part A. u rvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 9 - a ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local v� �� /� I �l If Referral,choose referral type(Fill one) <br /> Identifier: a� V b Y L ` w, l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> QQC��t CC�,Y fie S <br /> Physical Address 31 <br /> f lJ fD I A/ `sp �yn <br /> �?��D� S. �c�r�� ►�� . l lfiCJj7 <br /> 3� Inspection Date <br /> 1J 'I �C <br /> Time In Time Out <br /> Business ReTitl� � � � � 5' O PM � � � � Q AM <br /> oe r)n Is Uf��l.+,)en'Ae✓ /eym1ytC � l�(9 •PM <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 0 Active 0 Passenger qD Generator 4&Outdoor <br /> O 0 Closed 0 Altered <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 ® 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 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)(T) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years - -- "" --- -" <br /> I ' <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 w <br /> 0 0 Other: § in Compliance No Violations <br /> Comments <br /> Alin L4-"p <br /> 'CA <br /> Inspection Form Included: � / c� <br /> Comments Included: 0 �CC - <br /> Buslne Re Ignature Phone Number Insp c s Signature. Phone Number <br /> INSTRUCTIONS ON B CK IEIXIAIMIPILIEI1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />