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092SS040614 <br /> EllWaste Tire Su awy & Inspection Rep Inspection Reportt Number <br /> ;OHL State B CaliforniaCFWI 1' - . 10884 <br /> 04/04) <br /> California Integrated rWasteeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t .1L O 17101 M(DI Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: w (� (u�,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or acility`Name Inspected By Inspector <br /> (tA1,4 Vq,\ c —SeJV�Cis <br /> Physical Address —Fla � IG _ So% <br /> 13 3 �IUrmy <br /> Street , ^ � <br /> Inspection <br /> action Date U <br /> City ` State 7.l?Code Time In Time Out_ <br /> Business Rep Title a �OAM �h O AM <br /> d(V �"\I � F��S <br /> .J� PM 2 : �1V QPM <br /> om ="�� � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill-all that apply) <br /> t •Active Passenger • Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> _O Q Inactive Is Truck <br /> LongitudeQ— Planned OTR <br /> Q End-Use Container <br /> ® <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 §1 Other'( <br /> LCftf�5e�- ►fin I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of 1/iolation Q 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with.Manifesting Requirements <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/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 -46C_aOrWA 14-n-ALI- <br /> 03 f fo.Ae-A e <br /> Inspection Form Included: Q 909 <br /> Comments Included: 8-10--70;t <br /> Business Rep's Signature Phone Number sp tors Signature Phone Num er <br /> ■� 62081 <br /> INSTRUCTIONS ON BACK C rrec q Incorrect: X f1 M P (r 1 :2 3 <br /> White Co .CIW Yellow Copy:Operator Pink Copy:LEA ®. <br />