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Waste Tire S y & Inspection Re 000nspection Report Number <br /> Was p p � <br /> Ana State California I 1 1144045 <br /> CIWMB 181ornia /04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part ASurvey_ <br /> Business Profile Inspection Details <br /> — <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' L Q J ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local rr � If Referral,choose referral type(Fill one) <br /> Identifier: 3" 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Prj <br /> C Yv, ay1c) <br /> yslcal Address�1:tP.�Nc6/1����� � � - � G � ��� �t�2�cic <br /> 6. (6 r1Wit,m d-1` - -- - - - <br /> inspection Date <br /> ATime In Time Out <br /> Business Rep Title 3�l 3 I� i <br /> J V ' (1 OPM ' �P AM � 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � f <br /> 0 Active ® Passenger ® Generator 0 Outdoor <br /> j <br /> PS Latitude 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> G <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use ®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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other G ✓j�yyl •� ��,y( �-Lj — <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> 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 Date M / Ffl / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!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 is In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comments <br /> _ 7 _ <br /> Z <br /> Inspection Form Included: -- <br /> Comments Included: --- -- - - - <br /> I tsiness Rep's Signature Phone Number n ct natur — _ Phone Number <br /> ----- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect ,• i I � <br /> ■ - - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />