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Waste Tire Sur Y & Inspection Report ns ection Reportort Number ■ <br /> State B California Il - 1140639 <br /> Cgrated 1st(New <br /> Manag) 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- _ Inspection Type (Fill one) <br /> Site Suffix: / • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5L1,N -i�Jc,�y , ; , ,. t_� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 <br /> �7 Inspected By Inspector- 'S fcl­�7 S111 6e, (VA4 10:f <br /> Physical Address 3 5 U ��az�r��iswf�te�tw <br /> 3) r-d, �i`Y�a�f Rcl, - - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title S ® AM O AM <br /> d 0 P / 3 G aPM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r i 0 Active ® Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude 0 Hauler -� deoF <br /> O 0 inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use • 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 ® Other fl <br /> C1 r Ylr.,C.CJ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ------ <br /> ji <br /> V 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 [:F] <br /> / 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 <br /> (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 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 0 Other: § <br /> Comments <br /> � i2a.�frn��f�• ern �Z,r S dc�a/���rtao �.a <br /> Le1A r 140k C/ <br /> Inspection Form Included <br /> Comments Included: �S, ..tur. <br /> ® Business Rep's Sign re Phone Number Phone Number <br /> X <br /> EN _ 62081 <br /> INSTRUCTIONS ON BACK ' Correct:* Incorrect: ri <br /> J A ._._ ,P j— -... 11 3 <br /> White Cep, CiY.':."v Copy.Operat'r Pink py:L <br />