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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State°'°a"'°`nia Survey Form - Page 1 1 1 6 - 10 7 3 3 6 3 <br /> Callfomia Integrated Waste Management Board <br /> Part A-SurveV BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - I p� Insp tion Type o <br /> Site suffix: <br /> Sux: tine 'I Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose re er ill one) <br /> Identifier. ,Toa��{v/V/`�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V � Inspected By Inspector <br /> (�A(n.ehon eh.tta�tl2 ;ife ! . n _ <br /> Physical Address / — Q I <br /> 1 /0100 Y'/�/V o bKk\_P. <br /> Street <br /> I Tr a li/1 r)-P 7 Inspection Data <br /> City ( Slate ZIP Code Time In Time Out lJ <br /> Business Rep Title 0 AM 0 AM <br /> 0 P m'm0PM <br /> Operational Status Tire Type. Business Role Storage Type <br /> Tire CountWhole/PTE . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ' r r 0 O ®Active Passenger 0 Generator 0 Outdoor <br /> II O 0 Closed 0 Altered <br /> GPS Latitude l_ �— I Hauler Q Indoor <br /> LJA—_— l Q Inactive i IN Truck <br /> i O <br /> Longitude — I' 1 l— I i 0 Planned (DOTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber WKCjU c.. <br /> 0 Service Station 0 Hauler 0 Agriculture Q Shredder ®Othergp L ` <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation ®Extension <br /> ® 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DataD 1 O / <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB F0 <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> _...--.....—-------------—_ <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: �t �r .�/ / `— L ,([ <br /> Comments /V6( $ t7CRi Q / tisr j6ci L4 /,as c�k-H/�C leo( a l�/P <br /> �f Q / <br /> b re st �,re_ n �Jasfe.Tie ►— e�c5yr,t o-n om L'i wrn a 0)1\ <br /> q/7/off , Al 2�e�n��ien k S hot Nei been �a f d b outima. A <br /> ��cfi_eh,s�o► � o ti�n� has bye_�Gra izd fog/ ✓iola��'zar� <br /> Inspection Form Included: <br /> Comments Included: hof�(ln�eaNy�u/m�be <br /> r I v r turre. Pho <br /> ne Numberiness Rep's Signature Pus62081 <br /> INSTRUCTIONSON BACK ICorrect:6 Incorrect:X� I EuxrA�imiPkLIEI1112131 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LFA ® ■ <br />