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08GS2040234 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State■ °' ClwM IIll(Califcmia Survey Form - Page 1 1 6 - 10 7 94 3 5 <br /> crvvma tat(New oaoai i <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �� '/ �� (J / Inspection Type (Fill one) <br /> Site Suffix: S l j -Y 6 U ®Routine Q Re=inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: T���.t h �,w�6� Q CHP Q CIWMB' Q Complaint Q.Educational•Visit Q Other <br /> Business'or,Facility Name Inspected By Inspector <br /> Physical Address <br /> y <br /> I <br /> Street <br /> Siva, Inspection Date <br /> D ,62 Z O <br /> l C.<< G <br /> �-W,tCA �iS-Zoe t i <br /> ity State ZIP Code Time In Time Out <br /> Business Re Title O AM O AM <br /> P m:m EDPM <br /> Operational Status Tire Type Business Role Storage Type. <br /> ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 3 i d <br /> r ' *Active 0 Passenger ®Generator Q Outdoor <br /> Latitude I I l O <br /> GPS Q Closed Q Altered__ J ®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 /> ®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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements Date 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 EX7) <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 I 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 10 1 Other: § <br /> Comments <br /> ♦^.OtA�'Vlir_E Y_LC/�iFjtt:Ok��.-�1�—{.V�,C—L:�.� s Uu—r-1?q�j�""v,� <br /> _��5 Vu. �"-� d(,L�1LZf�—IKL91�l.eGG" �%SLS►Td�ala�-� Gt/Y�M--c�i.�s— /"P/O..'r�. <br /> Inspection Form Included:Q <br /> V <br /> Comments Included:Q ^ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (J� l�J AIll_ P•L E11112131 62081 <br /> �C lv <br /> . White Copy.CIWMB - Yellow Copy.Operator Pink Copy.LEA <br /> � I � <br />