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t 03217050044 <br /> Waste Tire Sui*y & Inspection Repor' Inspection Report Number <br /> ;Q;- State B California Survey Form Page 1 <br /> Ca i8�Integrated IwMB.181(New OM04) . I 1 - 1086938 <br /> California Waste Management Board <br /> I <br /> 'art A- Survey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 3 I O \/ I 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalI !. n j v O����� a\A14j <br /> If Referral,choose referral type(Fill one) <br /> �Identifier: (A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 13 Physical Address C <br /> 10 SOR s- T (A` (6,11 I 11 W <br /> Street <br /> (A I Inspection Date 10 171 <br /> 10 <br /> ) I 1019 <br /> 1 <br /> Cit -1 Slate ZIP Code Time In Time Out <br /> Business Rep Title + I AM l [() Q AM <br /> OPMal ' � PM <br /> Operational Status Tire Type Business Role . Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 0 <br /> f 0 Active ® Passenger 40 Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> Q Inactive Truck <br /> I <br /> Longitude – i Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q 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 • Other L-64 <br /> l <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A ,HAUL■INGIAN%MAN,IFES1TirREQUIREMENTIS <br /> Q Notice Of Violation (01 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 <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 EX7) <br /> Q Q 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 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q _ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliance - No Violations <br /> Q Q Other: § a 1 I <br /> Comments V Dom.LCIS <br /> ma-rAeA's - 1I55;� <br /> •�I�--o� 41�1 � <br /> Inspection Form Included: Q (31 <br /> Comments Included: ® -— <br /> Business Rep's Si ate a Phone Number (ns or's Signature.: Phone Number <br /> INSTRUCTIONS ON BACK Corr ct: I correct: EjIAjMJ F L I E1 1114131 <br /> 62081 <br /> White Copy. IW Yellow Copy.Operator Pink Copy.LEA <br />