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Waste Tire Suk .ey & Inspection Report Inspection Report Number <br /> moi State CIWMB California I 1 - 1143627 <br /> grated 1st(New <br /> Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ __- BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- � � O _ O I I Inspection Type (Fill one) <br /> Site Suffix: 16 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �G 7(yUl\n Cc�U n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address P,)e-n Es cAD <br /> Inspection Date �l 4 / ' V <br /> v <br /> Time In Time Out <br /> Business Rep Title LA 0 O AM Q AM <br /> 540 PM <br /> S ^ Operational Status Tire Type PM 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 /> f �J ® Active Q Passenger ® Generator Q Outdoor <br /> D Q Closed Q Altered NIA <br /> Latitude Q Hauler Q Indoor <br /> 0 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 ® 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 ® Other W 01 JC�n C- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- —_ - <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 j m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 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 ® In Compliance - No Violations <br /> Q Q Other: § L7 <br /> Comments1 ` t <br /> 61)l� �_1nsPec 1c�c�— s c�sc �� s C � c 1�._� L n USGS cd <br /> v o�uki nS bc-cule, ,,s-c, Co�cccn <br /> 4� �-��O Sim UVC,01 n l��S- -�t2� 7()N I rC 1 i f'�' <br /> ;Inspection Form Included: Q q q <br /> Comments Included: �I — I- `3�` �i Z� <br /> B ness R s Signature Phone Number �Inp tor' ignature Phone Number <br /> - _ <br /> INSTRUCTIONS ON BACK j Correct: Incorrect: X I X A 2 62081 <br /> _V_ <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy: ■ <br />