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Inspection Report Number <br /> Waste Tire Su. ley & Inspection Repor. <br /> N& <br /> State of California - <br /> Cgrated asteMana a Survey Form - Page 1 1 1 1 0 7 2 8 7 2 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / (� 2 Inspection Type (Fill one) <br /> Site Suffix: ! 3 ! ' Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> J/_+,j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Vie) �/ Sd Je <br /> v r'L� /1 Inspected <br /> By Inspector <br /> Physical A �Js <br /> 3 <br /> sT- <br /> Inspection Date C 2_ 3 / O K <br /> ��� C�4 pSZoS <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> � O PM O PM <br /> - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f &Active ® Passenger ! Generator i Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive !Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder i Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> li�Q 0 Notice Of Violation Q E. <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB / <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for N01/r„ <br /> O O -- - - -- --- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities ---------------- _. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r'; <br /> in Compliance - No Violations <br /> Q Q Other: § - <br /> Comments <br /> - - - OV i�1G /n1�S/Js2�%oh ®!� /`t� ¢. e /moi G T��/oYJr' �4 G✓aS �OT�c� : <br /> OA - 'C 1VA414- AC S. 3L7t e- Love t4c c <br /> %/la,USFsL Sr.4-7-/-OA), heig-a S r �'/i toe jajeen� XIV N. A V,o C.anaAdr <br /> Ole Cez,-ce4K5 AL re-e <br /> Inspection Form Included: Q r <br /> Comments Included: Q <br /> Business Rep's Si nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI1112 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />