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:II3 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State I3 California 11 - 1143572 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> "-rt A- Survey BLUE OR BLACK INK PEN <br /> siness Profile Inspection Details <br /> PID- ry – O I Inspection Type (Fill one) <br /> Site Suffix: ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SOLYN0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> —1 A -- J - <br /> Inspected By Inspector <br /> _^ <br /> tr �1( ` u r q _ (� c <br /> Physical Ad�ess� 1 3 I v <br /> a6a_3D S _ U01, Un {��• �J <br /> (�(� l / Inspection Date U � � /) � ( O <br /> MCA►CA(�1 t;'C,&, 1/� �5��*7 Time In 1 Time Out <br /> Business Rep Title O AM ^ Q AM <br /> 11 3 ' V V 40PM j 3 b 40PM <br /> - <br /> - -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ��( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Jl/ Q Active Q Passenger ®Generator Q Outdoor <br /> O 0 Closed Q Altered NA <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive � Truck i <br /> Longitude – Q Planned 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 /> J 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 <br /> Doti r� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> � li,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 / 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 EX7) <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 (a In Compliance - No Violations <br /> Q Q 1 Other: § <br /> �('' t <br /> Comments �L nA1,0A W&'%4t' �i r` l n5ne �I df\ / Uf1R- Un 1 S 1 <br /> �L <br /> o `�l�i fj11SWir-40, <br /> ,...Spection Form Included: <br /> Comments Included:® – -- — -- <br /> siness ''s Signatu Phone Number Insp or's Signature 4dJ"Phone 3Nu1 <br /> m-7b <br /> r <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: \z � A m P 112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />