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=, Waste Tire SL,. ay & Inspection Repo Inspection Report Number <br /> State B California I 1 - 1127692 <br /> Cgrated Waste <br /> eManag) 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- Inspection_ O I Inspection Type (Fill one) <br /> Site Suffix: `�^f 4@11 Routine Q Re-inspection Q Referral Q Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: SQA e) J a n CDAATT� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address1 � &) <br /> w6i <br /> u35 D NeLA)1 On n� <br /> 9.0c"60<1\ <br /> CA <br /> Inspection Date a i <br /> 111 1 <br /> Time In Time Out <br /> Business Rep j Title (� O AM O AM <br /> 0 PM oscmut\ --- -- - - - —� 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 Q Passenger ® Generator ® Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair ® Trucking Fleet O Government Q Retreader Q Dismantler O 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 114 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years - <br /> 0 O ' 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 /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 O Other: § <br /> Comments � r <br /> �,ot , �n5 f_(AL1L <br /> 1 l t)lAT.L10(- nC�c-�-� <br /> 61 <br /> Cy�SSS s u -- <br /> Inspection Form Included: Q <br /> - - <24 .a - s <br /> Comments Included. Q v <br /> - - - <br /> Busin ss 's S ature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X VV (: A M L 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L © ■ <br />