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■ £ (1 Waste Tire Su. „ay & Inspection Report Inspection Report Number ■ <br /> State B California I 1 - 1143978 <br /> CIWMB 181(teManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 1 A_Survey_ — -_ BLUE OR BLACK INK PEN_ <br /> iness Profile Inspection Details <br /> r•ID- Inspection Type (Fill one) <br /> Site Suffix: ` 5 tZ -5 o'2- l V I ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SOYA ��� �(�Vj / O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> ri <br /> Physical�Address <br /> Inspection Date 5 <br /> G r1n CA q5j0 3 l L lJ <br /> Time In Time Out <br /> Business Rep Title j L/ O AM O AM <br /> _ C C .PM l V 0 4W PM <br /> ill rl ��� � r1&k1-- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) c� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> y� Q Active Q Passenger Q Generator Q Outdoor <br /> O IS Closed 0 Altered P/A WC1' <br /> GPS Latitude 141A 0 Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - 0 Planned Q OTR 0 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 0 Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder ® Other il�hr�i�lcb��Z� <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility L ENFORCEMENT STATUS <br /> --- <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> �Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 010 Other: § L 1 `- / e <br /> CommentsTALI�Lr--lac) A C,,Cik---' A10 140L--17,'�' & (N (L'nCCe>t- <br /> �1���`�1/�-3— ���-�`.1C.� YIC��V-C�t��-_L�lw� ►yl�3��G%��� � - — --- - - <br /> 1 <br /> ,,ection Form Included: OI <br /> Comments Included: - <br /> P,Business Rep's Signatur Phone Number t -e 's Signature -_Phone Number <br /> INSTRUCTIONS ON BACK <br /> Correct: Incorrect 1 A P I P 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />