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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rri State of Cai�forn` <br /> Ctwma 181 thew 0u041 Survey Form - Page 1 I1 - 1088439 <br /> Caldornia Integratetl Waste Management 8-1d <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 1 So Inspection Type (Fill one) <br /> Site Suffix: Il ( v 1 0 Rapine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: '),_ c��'� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> AJ-o &n�cr <br /> Physical Address <br /> 3350 AcIcc, Roct� <br /> Inspection Date Y / J( I 09 <br /> rev C 30`( <br /> i Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> l O O ®PM G C_-,.� <br /> oE�! l C PM( r� . �rl t) � z��l� <br /> - ------ --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) R 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active i Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer 0 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> ---_ --- —_--------_--__----_..-----�---------------._.._.------__.__, 0 Notice Of Violation U 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 /> :00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FI / FI / 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 0 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 Violations <br /> Q Q Other: § <br /> Comments <br /> f,c -Yie. bbneK an JhI'S mak_ Ayla Alt- 6tc is <br /> Inspection Form Included:Q <br /> Comments Included:Q J7n. onBu ep Signa ure Phone Number eco.s Ste Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rr ct:i correct:X A M P L2 3 <br /> ' - Pink Copy LEA ® ■ <br />