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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Ili State of Caritorn,a <br /> CIWMB 787( e ( Survey Form - Page 1 I1 - 1088080 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � _ © I Inspection lype (Fill oncj <br /> Site Suffix: 4 � S a 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: SCLO J CL( Ul r) U>a U Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> Da1� 7, r� 3 - ► o <br /> Physical A ess <br /> g5a4a Inspection Date <br /> Time In I Time Out I <br /> Bus' s Rep Title e ^ : � O AM 0 AM <br /> 7?l j2 �SC OL✓/ c'7)- PM I S PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ( D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> IS 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 Q 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 /> — C) Notice Of Violation G Extension <br /> 0--U 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 �l <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W m m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 Referred 1 CIWMB Enforcement <br /> Q Q 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 •In Compliance - No Violations <br /> Q Q Other § <br /> CommentsWr �1Q `� IOndO fr'.� 15 a4e.. C l\A �% 1046 ,)101 UJG rU ' <br /> no \4,%O i o()S o s c-r uxs 0� cmces o . <br /> Na�� �. aQ�►� USS -16s e l ar�ll 'c�, o��ct Ytca{IE r st'�t0item 1, ui&Taf f evi av a <br /> - - <br /> Inspection Form Included:Q /f ZI �L yO�- 17�_ � 4 <br /> Comments Included:Q �( �}rFJt� <br /> Business Rep's Signature Phone Number Inspe is Signature one Number <br /> INSTRUCTIONS ON BACK Correcl%i Incorrect: <br /> )( yy V t, A M I P I L E 62081 <br /> Wrnte Copt!GW MB Yellow Copy Operator Pink Copy:LEA <br />