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082SS040018 <br /> Waste Tire Survey & Inspection Report _InspectionReportNNumber <br /> Creta 8,CaliforniaI 1 — 1088219 <br /> Cgrat. astoManag. Survey Form - Page 1 <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q I j Inspection Type (Fill one) <br /> Site Suffix: J i ! 0 Q 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SAS SOa4 .�- <br /> 0 CHP OCIWMB OComplaint OEducational Visit OOther <br /> Business or Facility Name <br /> Inspected By Inspector <br /> / -r— <br /> Physical Address <br /> Inspection Date 611e: / 12-I 2 / <br /> 8' <br /> S.+c C-ri: Time to Tlme Out <br /> Business Rep Title - 0 AM - Q AM <br /> O PM O PM <br /> LES <br /> 7-40 7-,- AXA 4ACI <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 appty) <br /> t 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O inactive 0 Truck <br /> Longitude - O Planned Q OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture O Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O 1 O I Other: § - - - - <br /> Comments QD q <br /> CSnIeJ_NS�LtT_i��efL%7i-iS _. i�tt �041-id_y 94AJ—r <br /> 7_l.�0�"f'_L/•'�Ise�_/Ca.o_Lole...�=�6_y ���—cCS— ✓�•a-�%t �'�-f.S_�r�+.•�.0 <br /> Inspection Forth Included:O 2O 4 <br /> 46a 46 <br /> Comments Included:Q <br /> Business Rep's Signature, Phone Number Inspectors Signature - Phone umber <br /> INSTRUCTIONS ON BACK orre :� Incorrect:VX(% g E X a M P L E 1 62081 <br /> 2 3 <br /> ■ White".1 <br /> Yellow Copy:Operator Pink Copy.LEA ® ■ <br />