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Waste Tire St ey & Inspection Repor ., Inspection Report Number <br /> til <br /> rrr State a California Survey Form - Page 1 7 Q $ l <br /> ciwMe tet(New oaioe) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPII)- � _ � 1 inspection Type (Fill one) <br /> Site Suffix: J j #Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n'v'1 VA 1000-K�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> BusinessorFacility Name v �Q y- Inspected By Inspector <br /> Physical Add+ess _ . <br /> 'Tev1 VN'1 <br /> 7Lt& GG>.G-p-te tom- WC"/ <br /> Inspection Date V Q <br /> shc4tb 0 C a. q 5 Zd-S V p' <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> Lill S 1(— 0 PM I 0 PM <br /> 1r Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (FN all that apply)' <br /> ®Active 0 Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered IVP$ Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O 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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility RCEMNT STATUS <br /> Y A: HAu-LtNc3:At4o-mANiFfi.srREO.UIROMENT:B. 0 yotica t1f Violation Q I~xanslon <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O !PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadlhle <br /> Q O PRC§42956-RegistrationlDecal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Ante I ' <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Regulred for NOV or <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 4 <br /> O Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Enforce <br /> an <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I <br /> O Q Other: § S�lt#Jtl 1�17.1fI�l�tRs f <br /> _._ <br /> Comments <br /> 'e t:J i.S-he rec etre -ffa,k ka, -- Wa sfe. Re co v a ry itk-st T h(► , -Gle Ca l'#D-s'04 ci <br /> bel ov* )1Ai45--}.5 o vcW aloe -41 514-L (3f y9 a,s) keft 'T'v es _-J-v Yd <br /> 01,+ d oor- i c� ur 1'nr;dq y, <br /> Inspection Form Included: Q� /-� <br /> Comments Included: -_JX % - 1 W U lP <br /> O Business Rep's net re Phone Number In pector' gnature Phone Number <br /> INSTRUCTIONS ON BACK f Ctethfi- y$ �3# 1 # l � / CE �r� �t �T 3] 62081 <br /> White Copy:CIWMB u Yellow Copy:Operator Pink Copy:LEA <br />