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Waste Tire.Su[ ;y & Inspection Repor: inspection Report Number <br /> ki; <br /> HIR- State of California <br /> California <br /> Integrated CfWfWastB 181 e Management Board S u rvey Form - Page ( Il 1086917 <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site Su <br /> TPID- ffix: I 5 I (� © • Routine Q Re-inspection Q Referral Q Observation <br /> Local C 1 If Referral,choose referral type(Fill one) <br /> Identifier: J�n�Quln W�1 Q CHP Q CIWMB -Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 "r, <br /> I <br /> S—d�s—N6k-w- NIS11 o n I _ <br /> 'Physical Address ' I �� ESGQfo- <br /> aaol� <br /> Street <br /> 111 u[[[ Inspection Date <br /> City State ZIP Code` Time In Time Out <br /> llll <br /> Business``Rep Title ]0 AM I <br /> PM a O SPM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I jgt (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> f ' �y"1 Active Q Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered N <br /> A <br /> Latitude <br /> GPS _ Q Hauler Q Indoor <br /> . Q Inactive ® Truck <br /> Longitude - ' !; I I i Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) Of ) <br /> Q New Tire Dealer Q Auto Repair ® 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS Q Notice Of 1/I lation Q Extension <br /> Q .I 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 <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 /> 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 I CIWMB Enforcement <br /> Q 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 In Compliance - No 1/iolations <br /> Q Q 1 Other: § <br /> Comments <br /> \ <br /> -k(12._I.� � <br /> �•lce_5=la Na. r ��� cvic�. crn-�vw hds o u,U►le�l ��►sS_i . <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspebtoes Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: neorrect: E. X A M R :L E 1112 3 <br /> White Co :CIW B Yellow Copy:Operator Pink Copy:LEA <br />