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ns ection Report Number <br /> =t=;, Waste Tire Surfly & Inspection Report P p <br /> 116 State B 181California1 7-.. 01 3 7 g Z <br /> CINtM8,8,fornia4iO4, Survey Form - Page <br /> California Integrated Waste Management Board BLUE O BN <br /> Part A- Survey ��Q�f}�� <br /> Business Profile Inspection Details V I U�-U a <br /> TPID- i Inspection Type (Fill one) <br /> Site Suffix: 1` 3 a g 1 '716 I Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ II If Referral,choose referral type(fill one) <br /> Identifier: [SWj0 - W " C Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "j Jin Ci-h' �{Stj Inspected By Inspector <br /> �G�Q���n;cA. e�u'ks�CaY n e��e S��f#� 3 9 Rl J_� <br /> Physical Address <br /> $fv(�0 co �ov� ed __j <br /> Street- Inspection Date <br /> i TCaGy q5P( Time Out <br /> City ! Stafe Z!P Code Time In <br /> Business Rep Title Q AM O AM <br /> I ,A-ly-Yoperational 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) , <br /> Active ® Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use ® 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 Q Car Dealer Q Collection Q Crumb Rubber PWd p <br /> Q Shredder ® Other 5 � O 7�-eG <br /> Q Service Station Q Hauler Q Agriculture - <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m I m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -_-_------------- <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: <br /> 11� 1(0)VJfl ` <br /> Comments -&41-__- tl` �/L� S S <br /> s� a h OrF_(Ca d av-ep, ?i s are- <br /> a i✓ofe- vQodw who r2�rns �� -fiY'es � CcsS`tow)ers. <br /> s, are Cle .ed_ W k- cLAA oUs o r <br /> Inspection Form Included: Q Q rLjfS <br /> Comments Included: Q — In tor's i ature Phone Number <br /> Business Reps Signa ure Phone Number 9 <br /> �-�/ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X(� X M P L 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />