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® Waste Tire Shy & Inspection Report*Inspection Report Number ■ <br /> F�13 State B California 11 - 1127482 <br /> CIWMB 781(New <br /> Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> s <br /> Site Suffix: t 3 $ 5 o { 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local '— 1 If Referral,choose referral type(Fill one) <br /> Identifier: 1 Q��w � � V1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V J Inspected By Inspector <br /> Q t aAz- 1 cu. ,l nG3 G1 — <br /> Physical Address J 1 ' o � ES AD <br /> L Ou,N Se.. AV Q,. <br /> UA��b� CA 15-330 Inspection Date ® 0 9 <br /> Time In Time Out vv <br /> Business Re Title q AM 1 0 AM <br /> Qn `` p I S OPM � O 0 O OPM <br /> ILt�nA1C� 1„un 0� 1 ,�(Jlf�l�,��" - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger 0 Generator Q Outdoor <br /> D Q Closed Q Altered N/A <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive 0 Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 /> 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 Q Other{{:§ <br /> Comments 1���(`� 1�1�Q,l�bn Pe�Osc�e��� (1(��C115. 11�.G�L"Q.. Gt,T1U�k�-�, TbllbllJl`C1� tl)-'�'• <br /> IAP_c llk)rvfu Hifi, 4 sactckmm � ;r dire_ der <br /> Inspection Form Included: Q r <br /> Comments Included: Q —��Eoin'ess Rep's Sign Phone umber Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incor ec - i 62081 <br /> ■ White Copy:CIWMB Yell3w Co y: perator Pink Copy:LEA <br /> V ' <br /> A <br />