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y & Inspection Re or"Inspection Report NumberWaste TireSu <br /> State a ifNew t,4,o4, I 1 — 1127489 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part ASurvey-_ <br /> Business Profile Inspection Details - - <br /> TPID- } Inspection Type (Fill one) <br /> q <br /> Site Suffix: t l g ` O L Routine Q Re-inspection Q Referral Q Observation <br /> Local � lj U� �• „/1 ��7 � If Referral,choose referral type(Fill one) <br /> Identifier v� 1 " `�/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Q���y �cA <br /> Physical A�rs <br /> 500 Lp v tae_ Are-- n, <br /> J� Inspection Date l z � Q <br /> L�,ih''�-p � J Time In 1 Time Out ` <br /> Business Rep Title ? O B PM � ®AM <br /> — J -- --- R _ PM <br /> V�4. _- J" — Operational Status Tire Type Business ole Storage Type <br /> Tire Count(Whole/PTE) , <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> B 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 ® Other U/ Y 1b <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V �q HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 1 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 1 Q 1 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> — - (Required for NOV or EXTJ <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ ------- <br /> 0 <br /> - <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q j Q Other: § <br /> Comments p�Cc��YI <br /> Inspection Form Included: <br /> Comments Included: _ - _- <br /> tur-- Phone-Num-berB � i nPhe Numbeec r' g <br /> 62081 <br /> INSTRUCTIONS ON BACK f Correct: Incorrect: ; ! Tf i � ` I 1 i Z 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co A <br />