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MjWaste Tire Su jy & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CWMB grated 1 teManage) Survey Form - Page 1 I 1 - 1143753 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ � I Inspection Type (Fill one) <br /> Site Suffix: J �p t0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: S Gl.n J Q UC{l,(l f'� C(�1J�i� 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> W\ `° P 3q 101 'I <br /> Physical Addre ss � � ES��I- <br /> IIILLL <br /> dub 10 A c ►ak Qc'N 'Ie. - - -- - - <br /> ���� Inspection Date 2 � I � � I V <br /> Seo C4 O n C Time In Time Out <br /> Business Rep Title 9 : 0 0 * Am q � � ISAM <br /> � _I O PM QPM <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) J( � <br /> 1% Active Q Passenger 0 Generator O Outdoor <br /> O O Closed O Altered NIA <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that apply) -fo—TIL 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 /> O Service Station O Hauler O Agriculture Q Shredder ® Other �Q.Ic.�oLtSe- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> y A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date T / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O -. -- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> i <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 0 1 Other: § <br /> Comments , MSOCAkon . k S- )III l 1 <br /> AIN k-k)Q,S Ojjc�'. <br /> ) aA� t' 6-Sc�uS <br /> CAi�e fc(\ Vl7 i 5 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Busin Rep's Signature Phone Number Inspec ignatur hone Number <br /> "-� <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:� ( �/l E X A P L 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y:L ® ■ <br />