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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> • !iI State of California <br /> Cgrated (New 041 Survey Form - Page 1 I1 - 1088441 <br /> California Integrated Waste Management BOaftl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: t C) 3 - G I ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalCC__ / 1, If Referral,choose referral type(Fill one) <br /> Identifier: Jt't1 xU00VA"-' ( ,t y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> �ct,�hsrn Chev><bfef _ <br /> Physical Address C1 <br /> 0AC) S. CVier0hee Ln <br /> Cam ��a�l!C� <br /> Inspection Date <br /> l <br /> Time In Time Out <br /> Business Rep Title <br /> Q AM O AM <br /> X 7 C 0 PM 3 OPM <br /> Je / -1 �r v?-C= ` m e -Storage age Type4Operational Status The Type Business Role <br /> Tire Count(Whole/PTE) ' /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t v 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> O Q Closed Q Altered <br /> GPS 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 /> 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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V_ ' A HAULING AND MANIFEST REQUIREMENTS <br /> Q�Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 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 Entities Complying with Manifesting Requirements Date M / M / El- <br /> 0 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 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 Q Other. § <br /> Comments <br /> RUv c rt�te )'1sFecfj?`n 6cne-__0-1 -this_ rant`, -4� <br /> �01�.<.�ti1c� was noi�� <br /> t�p vi e.�7iv7 6r 1yr&, O� 4�OVcCrrr_ <br /> Inspection Form Included:0 / <br /> Comments Included:Q-_ - .-G���iY' 0[ 7 r 3A/ G21Q - <br /> sines. ep's Signature Phone Number Insp c is Signa u Phone Number <br /> X 7-1P�TTTT13! <br /> INSTRUCTIONS ON BACK CoVr' <br /> Incorrect: � k X A M P'L � I 2 3, <br /> Wlh Cop Pink Copy LEA <br /> V <br />