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091313050003 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> •t State of California <br /> Cgrated 1steManag) Survey Form - Page 1 I1 - 1088045 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type (Fill one) <br /> ffi <br /> Site Sux: " <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �W__A <br /> �, If Referral,choose referral type(Fill one) <br /> Identifier: 5a n l n W� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other ; <br /> Business or Facility Name Inspected By Inspector <br /> R�eacn �r�,c,`2ic� 3 - 1 <br /> Physical Address b 9 <br /> -57-3G S. 1 ( 1 L— <br /> <1A0 6 n � /� ryao� Inspection Date y / L,t /� <br /> 1r_C 1 (vIL,1 �tltJn Time In ` Time Outl v I <br /> Business Rep Title ®AM AM <br /> �J 0 PM { O Q O PM <br /> 0/V<I G 12jWO�RAJ 12 C$I Lr'N Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f Q Active Q Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 10 Indoor <br /> O Q Inactive A Truck <br /> Longitude – Q Planned Q 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 <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 r ' <br /> V' ���-; HAULING AND,'MANIFESTREQUIREMENTS rx'' `y "' h ' <br /> Q Notiee`*f;Vtolati, Q Extension <br /> Q 1 Q 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires N <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compllance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle {{ moi <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W I I I l <br /> Q Q '14 CCR§18459.1 -Tire Program ID Number from CIWMB I I <br /> (R� cared fo <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days r z .,;. �, .k - NOV or ECT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years ,'r <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 /> t <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 1 t 1 <br /> p4t0�_d0c�a6n_k*_&,�_a-nC�" c�tpla��(A."_6e(�, <br /> ) kAse<s W-'16 f ujj Acts__Cks 4N�4( <br /> Inspection Form Included: Q ' <br /> Aar, .�1 e v 4y tJ•o <br /> dQ� A � 3 <br /> ' Comments Included: ® — <br /> Business Rep's Signature Phnn, Num_ber Inspe is ignature _one Number <br /> INSTRUCTIONS ON BACK Co ect: Incorrect: ' E X A MJPJLJEJ 111213 62081 <br /> ❑ White Co .CIW M Yellow Copy.Operator Pink Copy:LEA <br />