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Inspection Report Number <br /> Waste Tire Su. ay & Inspection Report ■ <br /> State of Survey Form Page 1 I1 - 1143752 <br /> California Integrated Waste Management Board Y - g <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S �- n Q - I Inspection Type (Fill one) <br /> Site Suffix: I I 41 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: Cl q urn � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L <br /> Inspected By Inspector <br /> ���� 3 5 - 1 0 1 <br /> Physica ddress ES,^ <br /> 4J5to&k0-r' CIS j�10 Inspection Date 3 I <br /> Time In Time Out <br /> Business Rep Ti(tll(e� /�, t () J O 0 AM i NAM <br /> W r k kAA1,, tl 1`1�11t�1� ICC. O PM L I I O _OPM <br /> ---- - - ----- - - --- Operational Status Tire Type Business Role Storage Type <br /> p <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � p o <br /> 41 Active * Passenger 41 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � Hauler � Indoor <br /> 0 0 Inactive 19 Truck <br /> Longitude - 0 Planned OTR O 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 /> OService Station OHauler OAgriculture OShredder Other <br /> (��.�n�c,�1GG.2, S oe <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 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 A In Compliance - No Violations <br /> 0 0 Other: § ! <br /> Comments t <br /> t <br /> rk_ Glfe(� CID V PO t��l U!1 0� <br /> Inspection Form Included: 0 /J� .1 - { <br /> Comments Included: ®I lY ii����a✓'t: � 4�!�V�l � - ��`)��� <br /> Busine s Signature Phone Number Inspect Signature 'Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct: Incorrect I J M I 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: ® ■ <br />