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nspection Report Number <br /> Waste Tire Survey & Inspection Report i ■ <br /> State B California I 1 - 1143629 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �l Inspection Type (Fill one) <br /> Site Suffix: V 01 © I * Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S CLO Joey LU n Com \A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> " v&SS F&_rM S a _ <br /> Physical Address 1 G ' en C�G01�U <br /> bb , Cod C , kA. <br /> Inspection Date <br /> `�b�\ "✓, L Time In Time Out <br /> Business Rep Title ' Z, � � 0 AM t � � Q�eOe PIM� 1 "U5S 1 W!t'C� �t- ®PM 1 <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 /> 1 d (0 Active ® Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Longitude O Q Inactive ® Truck <br /> Q End Use Q ContainerQ Planned Q OTR <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 r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other F'lt jm <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS j <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 /> / <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date � <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB Mm / m <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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 /> II , <br /> _A)_�-DI-wC�o ns- �e 0_S_ <br /> Q C 0coVC A fo cA4_04- c4, <br /> C�1-.-- <br /> - I <br /> ,Inspection Form Included: 0, 'ZO <br /> Comments Included: ®' `� - .4q;-Oa_ a <br /> Business Rep's Signature Phone Number Insp�Is nature - Phone Number <br /> - "` <br /> - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect f e x A <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy: <br />