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jWaste Tire Sui . ay & Inspection Report Inspection Report Number ■ <br /> Stateof California <br /> CIWMB 181( ew 04104) <br /> ryue 1 <br /> California Integrated Survey Form - PaWaste Management Board J Il 1143968 <br /> PartA-Survey-_-- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , -i q 1 9 1 ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Localif Referral,choose referral type(Fill one) <br /> Identifier sao7o&�ix,IfN CoW ul — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 9-, Lxr*vt��'S Pool fI` u5�e.s 3 <br /> Physical Address 9 - l I Ren r!CrJt'O <br /> Inspection Date 5 _ d <br /> ion CR �53�1� <br /> Time In Time Out <br /> Business Rep S TitleO AM <br /> (f O AM -t <br /> 4T C7 1[,1� O V ♦ PM -- - - d-- 0 O PM eTt�-`-- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) J Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �l I*Active 0 Passenger 0 Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (a Other Pool <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 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 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M� <br /> 19 [Co <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> S 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 1 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 Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments (10te-A 1, <br /> 1-_V Aaa� — <br /> �0W_CA�14 _ciJ fcy,cw <br /> Inspection Form Included: Qi �fQ �/ p• tip <br /> Comments Included: ® �F•`'SK7 7ls/ CaUJ 1�Qo <br /> Business Rep' igna at Phone Number Inor's sp Signatur hone Number <br /> INSTRUCTIONS ON BACK Correct:*- <br /> orrect:i, Incorrect: X E M s2os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy L <br />