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Waste Tire Su, .ey & Inspection Report Inspection Report Number ■ <br /> State of California 04104) Surve Form - Paae 1 I 1 - 1144006 <br /> California Integrated Waste Management Board Y g,/ <br /> Part A- Survey -_ BLU_ E OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- �-� _ f Inspection Type (Fill one) <br /> Site Suffix: r ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localr C - If Referral,choose referral type(Fill one) <br /> Identifier: �{� QUA <br /> ul nU.n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> mXT 3qPhysical Address <br /> Cn ����� Inspection Date <br /> H Time In Time Out <br /> Business Rep Title t 0 (� Its AM 0 AM <br /> 1 v V 0 P I 0 P M <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 /> Q Active 0 Passenger • Generator I* Outdoor <br /> a 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - i 0 Planned 0 OTR 0 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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder • Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V li A j 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 /> M / m / m <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/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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments Qbu[ ''la., W(4tr ���C�n` [iv i�Oe.�''!'Q s-r(b on_— Vic Q_ u�oA_ — <br /> Inspection Form Included: 0 <br /> 9 <br /> Comments Included:'+ <br /> &4( (V6%Businessyep'sSignature Phone Number Inp ors Sgnature onumber_ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X A ! $12 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink op . <br />