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Waste Tire Sul, y & Inspection Report ispection Report Number <br /> State CIWMB California I 1 - 114 0 8 7 0 <br /> St181fornia r04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _- _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( 3 �' 5 t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> IdentifierCQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ,J (j Inspected By Inspector <br /> -�C l/�G 1/ S 7-K/J i L c? W C.��'i <br /> Physical Address y 3 - �� 112- 4- <br /> Inspection Date <br /> h>C-1� i cam` �1 SLS S <br /> Time In Time Out <br /> Business Rep Title <br /> f� <br /> 0 AM Q AM <br /> O ® PM a PM <br /> tree Crvv>fr - - - <br /> - --- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> B Active Q Passenger Generator ® Outdoor <br /> Q Closed Q Altered <br /> 6-PS _ Latitude - - -T- - - - -- -- - - - -- E}Hauler <br /> - <br /> O Q Inactive Q Truck <br /> Longitude - ®OTR Q End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) _ �'►?r1JY�JC� —__J <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 Alavv z� _ 54i'600VIO-�f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS/ <br /> V 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. 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 / Ffl / <br /> 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 /> I <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/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 In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> �1u.����la c e�ai�,7iv✓ '7�1�.f f d��,x�c`-�v/ 7� .�1�Gt� - <br /> _L <br /> T_ <br /> Inspection Form Included: <br /> !1.! /d 205 <br /> Comments Included: - �� �6� <br /> ®' <br /> Business Rep' S na Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X F- I AIM � � i � ��3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy L <br />