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• Q92��4��� 54 <br /> ==Ilia_ Waste Tire Survey & inspection Report Inspection Report Number . <br /> Yr State B California I 1 - 1088363 <br /> Cgrated 7steManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I I s I ? DI ( Q1 I I 11 I Routine QRe-inspection Q <br /> Referral <br /> Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB QComplaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I ✓ r P't Q�W -TV—L+-CA I rDPhysical Address 131ql - 1 / I ��� � <br /> I <br /> f 01 oO `--l-Lhe P <br /> Street I O <br /> City I I / <br /> Inspection Date <br /> �I rel ���State 7_IP Code I Time In Time Out <br /> Business Rep Title I 4 (®AM 1 I �� Q AM <br /> ISI IO ;OPM i QPM <br /> JJ - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r1 (Fill one only) (Fill all thatapply) (Fill.all that apply) (Fill all that apply) <br /> ®Active ®Passenger *Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -"O Q Inactive Q Truck <br /> Longitude — Q Planned ®OTR Q End-Use Q 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 � �� ' , '�9• I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility trririulrj L ENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice 0 lfiolation ( <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 FE_ <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 /> 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 Q Other: § <br /> Comments Qb tM 4r , �n `� � � f1�f PS 'f►�Q �j c f u(1f�G_�l o_ 444 � ✓� LS <br /> 4n of r-e-i h s cffth.s bola td .�:�_lzi -f-o h av-c 1 a r aY�v � o>� t�es <br /> P� <br /> n 1C 41Z3, Ail <br /> - w <br /> Inspection Form Included: Q JJ ` oq <br /> Comments Included: <br /> ® usi.ess Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 09Trecril 10XIAIMIPILIEf . I11213I 62081 <br /> White CopyoYellow <br /> Operator Pink Copy:LEA <br />