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Inspection Report Number <br /> Waste Tire Sugey & Inspection Repor. <br /> Stats of 81.(N w I 1 - 10 8 8 4 4 8 <br /> Cgrated Waste <br /> Survey Form - Page 1 L" <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix 1t ISO I l 9� -_tom 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local , <br /> I If Referral,choose referral type(Fill one) <br /> Identifier: sa 1 J� ��` J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility N e { Inspected By Inspector <br /> Via_ 4 W A—P i_o_5 _I R�� <br /> Physical Address I - ! ILo <br /> I ( r�J l <br /> L _t,�D _1 <br /> LJAUI_A ��_. k Ahl_w <br /> Street FX, <br /> OInspection Date ,_ (��5 I �—I —_J i _i_I <br /> C t State L!?Ccc'a Time In — _ Time Out _ <br /> Business Rep Title I - I Q�0 AM --� • 0 0 AM <br /> n %PM I� , ' S S PM <br /> Operational Status Tire Type Business Role . Storage Type <br /> Tire Count(Whole/PTE) <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ' ®Active * Passenger • Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 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 /> IS 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 T A-1 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q Other: <br /> Comments <br /> Y + <br /> Inspection Form Included: Q <br /> 1 -�1Comments Included: -`— - -��— <br /> Bu p's nature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON ACK Correc : Incorrect: �� jEjjXjAAlt P '; 1 '2 3 62081 <br /> White opy.CIW B Yellow Copy.Operator Pink Copy.LEA <br />