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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State or Cali/arnia � <br /> C"- 'c,-"l gilled) -Survey Form Page 1 LL9 1 0 7 2 8 8 8 1 <br /> calif*Z Integrated Wast,Management 11-rd- — <br /> Part A. *ZX; <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: [-7 2I 3 C 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local Qn Octi� If Referral,choose referral type(Fill one) <br /> Identifier:' V TU�� C dun Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �G v�1�'�r_tern bar •113191I <br /> Physical Address - ( O f <br /> Street O / <br /> Inspection Date <br /> ity State ZIP Code Time In Time Out <br /> Business Rep Title �� --O AM 0 AM <br /> PM L ' Q PM <br /> 'Pe-ire. 1'ta1e,. I-Aana_er_-_-- JOperational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> I f Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude ; 'O Q Closed O Altered <br /> GPS i Q Hauler Q Indoor <br /> 'i0 Inactive Q Truck �A NIA Wa <br /> Longitude _ I Q Planned Q OTR 0 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 O 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 0 Other L( Od—Mq(�y� -1.lah(1QJ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS J <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Q § - Q Notice Of Violation Q Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O 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 /> O 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 I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> Q Q Other: § <br /> Comments an—t�ar`�aLmed d&c4e. 'tI T-o_IICJ+ui IYlQ—Wa.S_iL"% <br /> Sac�li�q �noE_sbI Lit.—w96o�'e.1'+3b_o.h�s�_.��.1.otS ue)n�c�es—serr�iJcre by�1c,C_A� <br /> J—. <br /> ''C[tf;�.k-1'x'4 Ser_�tiae.Ger_�er_,Snc t�as� �ic►_��i-:re�wece�'�oans.�or�ed ar_�-�r}� <br /> u�a5 Il 13 e ��=i _ ��1�ao_w�e—serlised�s� r 'P�'•e.—�a�e.• <br /> Inspection Form Included:Q 1-iyr,, Czar <br /> Comments Included: _ -NL —�pector's <br /> Y68-3179 <br /> Business Rep's Signature Phone Number a Phone.Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr et: Incorrect: t: X A MV P Lj9j 111213 <br /> ■ white Cop CIW/M Yellow Copy:Operator Pink Copy.LEA ® ■ <br />