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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 3 6 9 0 <br /> grated fst(New <br /> Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- S_u-rveT_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � ^' e� � � � - � I Inspection Type (Fill one) <br /> Site Suffix: `6 I 0 Routine ® Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ScLo J /,q�i C 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1�1 oU�cd�sti U�11� pf� - l <br /> Physical Address <br /> c GA ` 533�p Inspection Date (n I D <br /> QL(� <br /> Time In Time Out <br /> Business Rep Title I 1S AM SAM <br /> O G PM I I O PM <br /> -- <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 /> B Active 0 Passenger 0 Generator ® Outdoor <br /> GPS Latitude <br /> D 0 Closed 0 Altered 0 Hauler it <br /> ® Indoor <br /> 0 0 Inactive I& 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 I* 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 <br /> 0 Notice Of Violation 0 Extension <br /> O O <br /> 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 /> 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 O -- — ---- - - <br /> i 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 /> ioL� Other: § <br /> Comments Qrq\j USS� �IAXY 0Y-s I 10 <br /> t 01lai�(i offs 1/ SC�L�Qf�I <br /> Inspection Form Included: 2;;�Comments Included: - - �/' � 4 " ' � qBusiness R p' Ignat Phone Number Inspect s i n tureho��t Number <br /> � - - - <br /> INSTRUCTIONS ON BACK orrect:0 Incorrect X A 62081 <br /> M t ' L <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />