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Waste Tire Survey & Inspection Report. Inspectionepot a er <br /> StategtoBdof CalHornla Survey Form - Page 1 r.l 9 - 10 7 9 4 6 2 <br /> crwMe 1st(Naw 041 4) <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:. 3. S 0 S s 7 ' 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 Inspected By Inspector <br /> FPhysical Ad re3 - <br /> Tc7) 11 <br /> LAss <br /> I <br /> Street <br /> Inspection Date <br /> gs.Zp3_ <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 1 w, m MOPM IE 0P <br /> --'L ' b�M t"—Ixr�✓t 1L� - Operational Status The Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) II 1 I f <br /> I I t I36, 0 Active Q Passenger ®Generator Q Outdoor <br /> GPS Latitude <br /> O Q Closed. Q Altered <br /> Q Hauler Q Indoor ' <br /> Q Inactive 0 Truck <br /> O <br /> Longitude - �, J_ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) Ai A <br /> Q New Tire Dealer Q Auto Repair 0 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 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Pail B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> 0 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 / m / m <br /> 0 Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DC7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§1B460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q . 14 CCR§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q 1 Other. §, <br /> Comments i �a �,�4C l,�,, UGC <br /> - -'�^-er r�hC�'2CL-�9 tib CSYt <br /> r.. <br /> IF <br /> Inspection Form Included:Q <br /> Comments Included:Q �0(P2 <br /> Business Sign u Phon u r spector's Signa`` rfG a Phone Number <br /> —-- -- <br /> INSTRUCTIONS ON BACK or r correct:X)(� X A Mh 62081 P L I: E 2 3 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br />