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Y9!te Tire SL4y & Inspection Report inspection Report Number <br /> •8591:.. ifornia <br /> Cgrated Waste <br /> eManag ) Survey Form - Page 1 I 1 - 114119 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' Inspection Type (Fill one) <br /> Site Suffix 1 ' 13i6 Routine 0 Re-inspection <br /> ection 0 Referral r <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .�41 �.'G� t, �`� �� )j�t I0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> t Inspected By Inspector <br /> `r �(.) )`)� t A i <br /> Physical Address <br /> L_A L►_1_�`l_...�u!��..__._..__._�Y__..._._._.__...._...._._..__.� <br /> �ireet '�f G' <br /> Inspection Date � F O <br /> State ZIP Code Time In Time Out ` <br /> Business ReAM p Title ,,t- ' O PM O AM <br /> Si� , <br /> O PM <br /> Operational StatusTire 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> - O _ O Closed (�Altered <br /> GPS Latitude i , 0 Hauler 0 Indoor <br /> — — 0 Inactive 0 Truck <br /> Longitude — , I 1 I 0 Planned OTR End Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> /�- <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other L �/ejl7 t C1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - — — -- -- ------ ---- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § Vies <br /> f <br /> Comments IE /'ll "C / 11 ? ���� C--)l 1 e 5rr1 IS, <br /> b � <br /> Inspection Form Included: 0 . � <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1 E Xj!A,-M.i- P[L 1 E! 1 1 2 3�i 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />