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09192040214. <br /> wHi Waste Tire Survey & Inspection Report _Inspection Report Number <br /> State ofCalifornia <br /> IESurvLEe Form - Page 1 Il - 1108462 <br /> crvvMe I81 tet tNr+ewoaoa) � <br /> California Integrated Waste Management Board y g. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- p� Inspection Type (Fill one) <br /> Site Suffix: I 13 I I V—[9-11 _ <br /> J_ _, _i 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: <br /> E� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �__ x:� —_Cf a►_'lam __a , — <br /> Physical dresms <br /> _.23D 3 - j.0k�-r_p o_. .--- --- <br /> Inspection Date I V <br /> S�GK_ - C�.-q�_aas I <br /> City b�i !'? oGc Tlm_e In Time Out <br /> Business Rep Title I <br /> !� 3 QAM �O i 7 Q AM <br /> 4 ® PM •� QPM <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 apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ®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 I 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 Datem / 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 ® in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments �tJV6a , � <br /> Inspection Form Included: 0 ✓� c1 <br /> Comments Included: <br /> Business Rep's ure Phone Number Insp s gn ure Phone Number <br /> INSTRUCTIONS ON BACK C, rrect Incorrect: 1E11X a MJP[Ljtj 1112131 <br /> 62081 <br /> White C tv <br /> Yellow Copy.Operator Pink Copy.LEA <br />