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Waste Tire SuAy A Inspection Repo <br /> Inspection Report Number <br /> 7C State of BCalifornia <br /> Cgrated f(New gage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK IN_K_PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> ��Site Suffix: U1 (� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localr"" r If Referral,choose referral type(Fill one) <br /> Identifier: LSan Ja ulv(n lw[1,W Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physical re � � 1 O � �C��t,n-}�►- `J <br /> �, �S�-Yl N, 76 CA, <br /> Street <br /> l H+ Inspection Date <br /> L-11City ` State ZIP Cod Time In Time Out <br /> Business Rep Title O AM 1—i —�� Q AM <br /> toPM - 0 P <br /> --- r`- �- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) T7. <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � ' <br /> It Active Passenger ® Generator Outdoor <br /> I0 Q Closed Q Altered <br /> GPS Latitude i 1 Q Hauler Q Indoor <br /> - -__-r'---_ _--_ _-__--_---_-0 Q Inactive 0 Truck <br /> Longitude - i Q End-Use Q Container <br /> Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other t �I ul skDe I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <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 EX7) <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 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 0 In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> c 1 • <br /> Comments <br /> C JJ <br /> JVA-V �_onSp-C-G,k�S c�—ion. <br /> Inspection Form Included: Q <br /> �0 5 37 5' 066 <br /> Comments Included: Q — - — <br /> Business ep's Signature Phone Number nsp or's'Signature . Pone Number <br /> � X <br /> INSTRUCTIONS ON BACK Co ect: 1 orrect: 7.9( (% � � P 'L E 1 Z 3 62081 <br /> White C y:CIW Yellow Copy:Operator Pink Copy:LEA . <br />