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L Waste Tire SSey & Inspection Repo Inspection Report Number <br /> State of California ;� !}"y( (� +�� tjy jjt <br /> w 04104) <br /> California Integrated,Waste 81 eManagement Board Survey Form - Page 1 1 7 1 Sf f 9 2 5 ? <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Pro ; Inspection Details <br />+ TPID- r _ Inspection Type (Fill one) <br /> Site Suffix: [=L FG T 1 -5 V _j 0 Routine 0 Re-inspection 0 Referral (2) Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: i11 TdQkA,Cl C,O U f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> M ach,f1kT-A 1 <br /> Physical Address -.33 ' Q I 1 <br /> I K.0 I SY 1 an LU Co,& I <br /> 1 ?)(-)L1 �T_QAa0 Ste. 1 <br /> Street <br /> Inspection Date <br /> 1 C 2'R C Ct m►1iCA 952 31I - <br /> Cit. ---T State Zlp C oOut <br /> Time n Time <br /> Business Rep Title O AMAM <br /> SeCY1ce PM i O PM <br /> C1 <br /> Operational Status Tire Type Business Role S eige Type <br /> Tire Count (Whole/PTE) (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 2/— 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 1�J�10 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude — Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 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 Other V� E9tlI p. �p�Q�(_ a �4S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 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 Date m / m / m <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 /> 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 0 In Compliance - No Violations <br /> _0 _0 Other: § <br /> Comments <br /> n�t�l c R 4_(�_emaVq_k -T fo rn <br /> VICIVurn.2 ���������e <br /> Inspection Form Included: - <br /> Comments Included: 0 = �-- <br /> Business Rep's Signature _rPone Number Ir}epector's Signature: Phone Number <br /> ... . _ q-- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � � F X 62081 <br /> A ,�',iP I_�� 1 � 13 <br /> _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />