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Inspection Report lumber <br /> M <br /> ,1 Waste Tire SL ►y & Inspection Report ■ <br /> Uf;ii- State of California _� <br /> CWMB 1(New <br /> Manage) Survey Form - Page 1 I1 - 1140917 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: D ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 115GVY1 �/ CZ�,�(,f h� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> -- - -- <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> van�C-C l orc1 G <br /> Phys cal Address <br /> ciao cr r+ <br /> SSS f (c,i17 - <br /> Inspection Date i a <br /> Mail k cc- `j'5;.33 <br /> Time In Time Out <br /> Business Rep Titleo 1 0 AM oZ ^ 0 AM <br /> 0 PM v 0 PM <br /> /1 <br /> CrIa I ,n S&y Oct ,`Cep1 K -- - -- <br /> -- - 1 Operational Statusl Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 f (Fill one only) (Fill all that apply) (Fill all that apply) j (Fill all that apply) <br /> J j ® Active ! ® Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> 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 /> 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 /> Q 0 Other: § <br /> Comments 7 <br /> — <br /> I <br /> !Inspection Form Included: 01 X <br /> Comments Included: ® -- �-S <br /> Business Reps ignature P e Number spectwls Signature Phone Number <br /> - _ - - <br /> 62081 <br /> INSTRUCTIONS ON BACK correct o EII ASM L -_ 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y. <br />