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Waste Tire Su-iey & Inspection Repo* Inspection Report Number ■ <br /> "II3u.,6 State of California i 9 r, _� Ps fs p5 <br /> iif CIWMB1811 Waste <br /> Survey Form.. - Page 1 _ �€ <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> - <br /> Business Profile `" �Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (��-f ? ' q� LQ Routine Q Re-inspection 0 Referral Q Observation <br /> —OLd <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S(arl D-O aq Gakf) Count ij Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Pnmresn <br /> ►-- A_H _._ a. .1F c n �a c, Irl J -� <br /> l..ucf <br /> Street y -- FP <br /> Inspection Date " -93LG� � �1„�[7 � � it <br /> Time In V J�j Time Outtl _ <br /> "iii; � ,state ZI Cade __ <br /> Business Rep Title y 0 AM AM <br /> EE : <br /> 1 0 PM _ 0 PM <br /> Tr E) <br /> Operational Status Tire Type Business Role <br /> Storage Type <br /> (Fill one only) (Fill allthat apply) (Fill all that apply) (Fill all that apply)I <br /> Y)Tire Count (Whole/PT <br /> ® Active 0 Passenger Q Generator 0 Outdoor <br /> --- O <br /> Latitude 0 Closed O Altered <br /> GPS �� LLi777-7� <br /> __.". Q Hauler O Indoor <br /> O O Inactive 0 Truck <br /> Longitude - O Planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B- Inspectiiorn of Waste Tire Dealer, Generator, Hauler and End-Use Facility L ENFORCEMENT STATUS <br /> V ; A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation O Extension <br /> 0 O 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 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 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 0 Referred/CIWMB Enforcement <br /> 0 Q 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 <br /> Q In Compliance - No Violations <br /> 0 0 -- <br /> Other: ---.___------.--------- <br /> Comments <br /> r \A -A- fie r. 1sP. - <br /> Inspection Form Included: 0' <br /> Comments Included: 0 - - --- - -. <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X jl�, V I `�I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />