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. iJ�l1l tl�Iki�ti53 <br /> = !a;, Waste Tire Su, 3y-& Inspection Report Inspection Report Number. <br /> 010 litin- State of California - <br /> Cgrated Waste <br /> eManag) Survey Form Page 1 1 2 1 0 7 9 3 1 6 <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 /> Site Suffix: [Jj 3 r� -7 ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , an 'o 4- 0 CHP , 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Businyye�1ss or Facility Name 1 Inspected By Inspector <br /> Physical Address v / Q <br /> Street <br /> Inspection.Date <br /> City State ZlP Code Time In Time Out <br /> Business Rep Title AM n 2 ®AM <br /> Q D ri/ > O% I O PM O PM <br /> --- - " — Operational Status Tire Type. Business Role Storage Type <br /> I ' l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) �;D <br /> 0 Active 0 Passenger 40.Generator (a Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude ,�— I I � 0 Hauler ® Indoor <br /> IO 0 Inactive 0 Truck <br /> Longitude - I I , I I�1 I 0 Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) J 111 111 <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 ,1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other I l/`���_! /�-•rte/4.�1 � <br /> i <br /> Part B Inspection of Waste Tire Dealer, Generatori Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULINGAND MANIFEST REQUIREMENTS 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 <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 Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§_18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: ,§ <br /> Comments <br /> 7 /,?C G/L l 8 Y d dt — lZe4-- ,'Y"�' d *-r I�C�u-��r��..o-.:.t►�1 Q��e its-+� <br /> ir< ��cc rs — owe 1�1r'L u.Gy vK v4L. aa,- <br /> /L,'r lL=/�i 's ou <br /> 47 <br /> t 2�g <br /> Inspection Form Included: 0 n <br /> Comments Included: 0 3 3Y <br /> Busines p's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 10XIAIMIPILIE1, 1112 3 62081 <br /> White Copy: IWMB Yellow Copy:Operator Pink Copy:LEA <br />