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Waste Tire SLP, y & Inspection Report nspection Report Number <br /> State CIWMB California I - 114 0 6 7 5 <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- _ G Inspection Type (Fill one) <br /> Site Suffix: f �j 3 T J 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ..f00.„ I ..V, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical Address J / Q Ayyv'rjda gjot4'fiY" <br /> - <br /> Inspection Date 0 c� / t U / ` 0 <br /> S+0cdot-cr CA <br /> Time In Time Out <br /> Business Rep Title * AM AM <br /> Sllu,- O PM I r O PM <br /> Sl�� to -- --- --- <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 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered NSA <br /> GP� Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 Planned ® OTR Lo 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 <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 - -- _ --- <br /> 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 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years j <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 Other: -- <br /> Comments <br /> rnA.In m e- i nm r� UYn-kIA S Z�Ube Fight o l"d r vXc <br /> +-o !n In ct_c.tlL Ad1 0_r I Y, --i n r - y"oa-'C( <br /> Inspection Form Included: <br /> Comments Included: a `d 3 <br /> nese Rep's Signature Phone Number nspectoes Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X _X A P, 1 2f3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y: <br />