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Waste Tire Survey & Inspection Report Inspection Report Number. ■ <br /> srl'°rCalifornia <br /> ow Survey Form Page 1 [-1 2 1 0 1 3 6 7 9 <br /> CIWMB ted(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OQeSL, K{,. .EN <br /> Business Profile Inspection Details <br /> TPID- J / Q Inspection Type (Fill one) u t►it�f <br /> Site Suffix: / 7 0 l 1 / j Routine Q Re-inspection Q Referral Q Observation <br /> Local C� rl� If Referral,choose referral type[Fill one) <br /> Id <br /> Identi Q <br /> Identifier: �q,� � h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> i 17le 9<_ "Z_e / �VS I _ rt (�AT�9Gs%4 <br /> Physical Address <br /> treet D <br /> Inspection Date <br /> State Zip Code Time In Time Out Business Rep Title 0 AM 0 AM <br /> 3 3 16 0 PM �Tyj'!�7_ 0 PM <br /> -- — — _ Operatlonal Status Tire Type Business Role Storage Type <br /> I Tire Count(Whole/PTE) / n O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger •Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> — _D Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <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 /> Q 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 i _ _ I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I 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(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 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 /> Q Q Other: § / <br /> CommentsS 41 ,elGa�/_ G2 t jou,f• Z.�ca.r�9f�1 - <br /> -r <br /> bk'.ez "04""A' fg oce IPA <br /> Inspection form Included:Q <br /> Comments Included: <br /> uRne�ure <br /> _ Phone Number Inspector's Signature Phone Number <br /> • ��� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P LEl Z 3 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />