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09182040211 <br /> Waste Tire Sway & Inspection Repor*- Inspection Report Number_ <br /> State of Cardor w I 1 1108408__ <br /> Cgrated asteManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I / I i Inspection Type (Fill one) <br /> Site Suffix: L I� 3 ( j 3 j I .tp i I �� I ® Q P Q Q Observation <br /> _-J Routine Re-ins-inspection Referral <br /> Local Ii If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �J V Inspected By Inspector <br /> e C Q <br /> Ad FF�s�e �ra►'►�'�5 ' j <br /> Physical ess 3 I � <br /> ��Vll Lt <br /> Inspection Date <br /> L_!_ 0_ <br /> 1 I-I 0: 9 <br /> Time In Time Out <br /> Business Rep Title -- ®AM ;- -I -i O AM <br /> Yl Arn-off--pe gook kPe O PM O ® PM <br /> - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill'all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger @'Generator t® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <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 L <br /> Q Service Station Q Hauler ®Agriculture Q Shredder ®-Other ! Q/rYl rOk c - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 1 <br /> VMIMAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <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 <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 1 0 1Other: § --- j �^ <br /> Comments LK�� /yam _—J Wit_-$ [�l f� T��P s h�C7LtlZ►'�Lj _ - �l <br /> rla l cY e &rV"lc Ozone �j c� I� j/ , � pct wrc "j01_m tirl �r OT - <br /> '�e , <br /> LV 61 u. TY17 FAT kkig- u`�e S� I�r�►m s ✓ierI, � <br /> Inspection Form Included: Q Qlq. q&_%g01y <br /> Comments Included: Q — <br /> Business Rep's Signature Phone Number Inspector's Sig ture Phone Number <br /> INSTRUCTIONS ON BACK 10XIAIMIKLIE1 11 [2T-31 . 62081 <br /> White opy:C M Yellow Copy.Operator Pink Copy.LEA <br />