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;1.>€ Waste Tire Su ay & Inspection Report p p <br /> Inspection Report Number <br /> Liam -State of California I � 1127540 <br /> CIWMB Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ _ _ BLUE-OR BLACK_IN_ K_PEN <br /> Business Profile Inspection Details <br /> TPID- � � - � I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1�(,tp JQ 'tip n town 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1� <br /> Inspected By Inspector <br /> Scu�`� �CvA o<spor4lo A 5 - L 4 l Qerl <br /> Physical Addres 3 <uj7ti <br /> Inspection Date <br /> Time In �f Time Out 1 <br /> Business Rep Title 5 0 AM 0 AM <br /> �'('' 0 PM 3 a PM <br /> �JA'�-S SQJ�DI,(� JuQc�Vl�Sbf' - - --- - - <br /> ` Operational Status 1 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 /> I 4k Active 0 Passenger 0 Generator Q Outdoor <br /> O 0 Closed 0 Altered <br /> GP$ Latitude Q Hauler 0 Indoor <br /> 0 0 Inactive ID Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 �� rl 61QT <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j 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 4, 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 j'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 j In Compliance - No Violations <br /> 0 0 Other: § --- - <br /> Comments l I 1t3<DU6r\ 0 Vs ' <br /> .Inspection Form Included: 0 ' eCIVIB <br /> )Comments Included: = - � — 2 - - (0 -B mess Rep's Phone Number Inspe or's SignatureINSTRUCTIONS ON ACK Corcorrect: X 1f x( AAA ' 1 s2081 <br /> White Copy chow Copy:Operator Pink Copy:LEA <br />