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® iiia Waste Tire ftey & Inspection Repo* Inspection Report Number <br /> State of California 11 1088074 <br /> Cgrated Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA- Survey BLUE_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q 1 Inspection Type (Fill one) <br /> Site Suffix: j} l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: h L�� �< Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Ali rnetn M44o ` - <br /> Physical Address <br /> E( locyv'�)o �S+_ <br /> Inspection Date 449 Z / O <br /> Time In TimVe Out l <br /> Business Rep Title 57 3 O AM O AM <br /> R 0 PM O PM <br /> S �' - <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `-� ® Active I§ Passenger 0 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 End-Use Q Container <br /> Q Planned Q OTR <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FORCEMENT STATUS <br /> A j HAULING AND MANIFEST REQUIREMENTS <br /> - ,Notice Of Violation RE , n <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. -mpliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 lCIWMB 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 /> Comments IQJme, rls�,Dn (Nt' m Jfils_Wil./ GCwLC <br /> •V� l �— t re ms��eS lleY e,jcL��'�C_ <br /> ►amt <br /> 'r-T-1 An-/ o� L�'y - .�.-rte 1 GZL - <br /> o <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> usines4Re s Signature Phone Number InspeMr'-dSiiture Phone Number <br /> INSTRUCTIONS ON BACK I&JAIMIPILIE1 1112 3 62081 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />