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0921004025.1 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> -*Pt <br /> �P State of California <br /> 81 04) <br /> California IntegraM d,Waste MaOnagement Board Survey Form - Pagel Fil 10-88311 <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> L� <br /> TPID-Site SufInspection Type (Fill one) <br /> fix: O 16 --� EcLil <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local //� If Referral,choose referral type(Fill one) <br /> Identifier: ��(,�Q V t l� C.�IJ✓� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Llt�k,1GO I,Y'� S►la� I _ <br /> Physics Address lo d 1kw)_' mo <br /> i -7at -2 . <br /> Street h <br /> �1^� Inspection Date <br /> _15RvD-J Time In Time Out <br /> City State LIP Code <br /> Business Rep Title EFI <br /> I �O AM iQ AM <br /> - f U 0 PM �J <br /> — — - Operational Status Tire Type Business Role Storage Type <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire-Count(Whole/PTE) <br /> ®Active • Passenger 40 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude i, : Q Hauler Q Indoor <br /> _0 Q Inactive Q Truck <br /> Longitude — i Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other l I <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 QQ Notice Of Violation Q xtension <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 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 EXTJ <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 1 Q 1 Other: § <br /> Comments ,lp ,°��-�h� —&4f anc� - hf- <br /> 4)r✓bS Y1(ZO�y�J� <br /> Inspection Form Included: Q <br /> Comments Included:Q < <br /> Busi ess ept,Zliqnturne umber In c ors qign4ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BA C rec I E X R MVI P LIE[ 1 2 3 <br /> Whi op . Yellow Copy.Operator Pink Copy:LEA ® . <br />