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0$325040068 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CrwmrCad fornla Survey Form - Page 1 I1 - 108833444 <br /> Cgrated astleMr nae . Y 9 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Fr Inspection Type (Fill one) <br /> Site Suffix: L)� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name VVV In By Inspector <br /> ysTnce` ►�" ck-c,n9 p J c <br /> Ph <br /> sical AddretsCj <br /> Street V" U Inspection Date F O <br /> -`fob' i 95 0 (0 <br /> Cit;, State ;I,Co,, Time a In_ _ _ Time Out _ <br /> Business Rep ^ Title ? O AM j O AM <br /> -Qi I Y F I �; ®PM O PM <br /> -- --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' /_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r lQ ®'Active Q Passenger 4D-Generator ®Outdoor <br /> O QClosed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - o Q Inactive fM 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 ®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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / 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 EXn <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/CIWMB Enforcement <br /> Q Q 14 CCR§16461-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 (a In Compliance - No Violations <br /> Q 10 Other: <br /> Comments T�� I r'L�,RP C�..�"+'*` !yt,l.S �Q/ �� •e-S T[ilJt l�_�� <br /> Fay 1-;471-_ �SeSj�rCc.yin Oki 7%✓ �' � aev'✓i c� 4 <br /> w, 05 rh u vrnCc.StA �- o-w),S ✓iP.vy-e-d ala <br /> olc,-fens Pio ed- <br /> Inspection Form Included:Q <br /> Comments Included:Q 7rPol �� <br /> Business Rep'aEftnature Phone Number Inspect4,eSure Phone,Number <br /> INSTRUCTIONS ON BACK Correct 0 ncorrect: 0q EXAMPLTE 1 ;2 3 62081 <br /> ■ White py:CIW Yellow Copy.Operator Pink Copy LEA , ® ■ <br />