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® = Waste Tire Su. .E & Inspection Repoi _ _ pection Report Number <br /> State of <br /> Survey Form - Page 1 I1 - 1140935 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey-__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � � _ � � Inspection Type (Fill one) <br /> Site Suffix: O Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: SICKA Y\ C... X)Vk. 11� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> f;Al' rlo`�o;1 _ l <br /> Physical Address Q1 � 1ti1� <br /> am5-5- 4"c"Is- <br /> /� <br /> � Inspection Date 1 Cj r� <br /> "� ��aa o Time In l Time Out C.•/ <br /> Business Rep Title l O AM O AM <br /> l Q PM l 05 <br /> O PM <br /> Lk� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n� (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 /> — a a Closed 0 Alte et1 Al114 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive 0 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 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> I <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 /> 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 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/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: § .�1� <br /> Comments Ylt�1Zi� SY►. ee--h&n pe! m-eL [�1Y6t� _—dn VytdeJ-)z <br /> 1A-e)Crrs n o 1��✓ rte.-I-rvr Ai,x C Jr `�S e c , Aar� '_4r2-tel <br /> n 3-LI i cl 77',ZV # 14&S, <br /> Inspection Form Included: 0 L ti, (,, rG�,17JY <br /> Comments Included: 0 — 4 ty -- - — lQ �, �Z <br /> Busi ess Rep's Signature / Phone Number In e i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: XI �/I E X A L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: ■ <br />