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Waste Tire SL06y & Inspection Repor ., Inspection Report Number <br /> State B California I 1 - 1088271 <br /> Cgrated Waste <br /> eManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- ( -7 ' � !I _ I Inspection Type (Fill one) <br /> Site Suffix: _� � . Q Routine Q Re-inspection Q Referral Q Observation <br /> Local11 If Referral,choose referral type(Fill one) <br /> Identifier: `' ��� 7ortr�t-IIS C-�'url't � <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ir,� b Tire Ccn+cr I <br /> Physical Address [ S U ' Kr I�tlan LuCq S <br /> .� 3 5 q E . <br /> Street LJ <br /> Inspection Date <br /> I Sfi�c.k�on C-A 95zQ I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM � ' 0 PM <br /> - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I I �1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> lJ Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® 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 O Auto Repair O Trucking Fleet Q Government O 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 ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 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 Q In Compliance - No Violations <br /> Q Q Other: § _ <br /> Comments p � t-r*15 C� f u W►Y1C W ri <br /> no�elc is pprox. IgLU _�a��e ��r 5 5kofc,3 zr -�►�-� ir) -a conta►rier ._ <br /> FOC111 1 `tIt e� IJG�12. �CG�V�r4 Ltj r LooJe_ +i,(v- CQrnOYcA\ �r(jrr� % <br /> tic . E-� mo 1'O r w G`eke -{Ire (emoya Vwte per) r e <br /> Inspection Form Included: Q �. <br /> i = <br /> Comments Included <br /> Buslness Rep's Signature Phone Number I ector's Signature % Phone Number <br /> /� i P. IL E 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: it J�,' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />