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Waste Tire Sur...-y & Inspection Report Inspection Report Number ■ <br /> State of California <br /> Cgrated 1(New04/04) Survey Form - Page 1 I 1 - 1143602 <br /> California Integrated Waste Management Board <br /> "art A-Survey —_ _ „ BLUE OR BLACK INK PEN <br /> Isiness Profile Inspection Details <br /> j pip- - � I Inspection Type (Fill one) <br /> Site Suffix: (6 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Is(A qoal�,(`I\ �l1Wn _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �. Inspected By Inspector <br /> JrJ�r T.vu� � �n�� � - � o RQ <br /> Physical Address 3 ( (-n ES U60 <br /> CA Inspection Date �1 � � I � l n <br /> J Time In 111 Time Out 1 V <br /> Business Rep Title O 1 r 0 AM Q AM <br /> �ov10 r\j 1A ?)U92CTU /Jugvr J PM e PM <br /> - - -- ------- - — - - Operational Stat Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �j`' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> N Q Active Q Passenger ® Generator Q Outdoor <br /> —0 ® Closed Q Alteredof NJ/� <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> FO <br /> Service Station Q Hauler Q Agriculture Q Shredder OtherGrl <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> ------- <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 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 DCT) <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 i 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 Of\ 7NS Lk e_ kvLI111 <br /> I.._,,ection Form Included: Q I n/� r��{ <br /> Comments Included: 111111! �ai e-A - ---- �c Com`"1J -��'3� / V <br /> �j Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect ✓, XC E A MI PILIE1 11 ; 2 I v i 62081 <br /> ------ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />