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03210040237 <br /> rC99a <br /> Waste Tire Su -y & Inspection Repor Inspection Report Number <br /> --tom State of Calif81 ornla ew a' — <br /> California Integrated,WastJe Management Board Survey Fo rm Page 1 I 1 1088429 <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type (Fill one) <br /> Site Suffix: [ I 0 I ���� U I� MO / <br /> 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCjGD Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address �C— <br /> I CA-eAz kP—L L.o� , <br /> Street <br /> /,�T � Inspection Date FD&I � / 9 <br /> I <br /> City Stag ZIP Code Time In Time Out <br /> Business Rep Title - —� L�� 10AM ' 1 --_ 0 AM <br /> I® PM I j CLO ® PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> f J ® Active ® Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 1 • Q Hauler ® 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 /> Q 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 0 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 FacilityENFORCEMENT STATUS __ <br /> V j A HAULING AND MANIFEST REGlUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 <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 Q Referred/C-IWMB 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 1 Q Other: § <br /> Comments o ` <br /> k� -tire fzyc�lSpos�..s . CrL <br /> LI Q V 1 0 �u Z-L S PLO fi . <br /> Inspection Form Included: Q <br /> Comments Included: Q •Jy-�j7 �9-� <br /> Business Rep's Signature Phone Number Inspector's ignature Phone Number <br /> INSTRUCTIONS ON BACK "'e0cIncorrect: 62081EXAI►4R 'L E I ;2 3WhiteYellow Copy:Operator Pink Copy:LEA <br />