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j <br /> Waste Tire Su. ody & Inspection Report inspection Report Number ■ <br /> State of California 11 - 1143975 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> P--t A-Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> - Inspection Type ( -in <br /> Site Suffix: 9 59 J l 4DRoutine Re-inspection0O Referral O <br /> Observation <br /> Local J� If Referral,choose referral type(Fill one) <br /> Identifier: �1ncbv� � � `�/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V / Inspected By Inspector <br /> Physical Address <br /> ,5,560 yv <br /> f �y� Inspection Date <br /> GA Time In Time Out <br /> Business Rep Title C ®AM AM <br /> r 7 o PM I O PM <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O e Closed Q Altered <br /> GPS Latitude "/A O Hauler O Indoor <br /> O Q Inactive Q Truck /j/A /V/14 <br /> Longitude - O Planned Q OTR O End-Use 1 Q Container <br /> Business Type (Fill all that apply) _ <br /> lew Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder ®Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULINGAND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> OO <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> QO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FT / <br /> 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 EX7) <br /> 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 i CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> L <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 O Other: § i_ <br /> Comments -rY►��l?�.� tYi����-h� &nA22 c1cc\3 --AL �� 5-A-in—IL-,L`i1,,2MS Or -4 <br /> 6�y cU�►'�. a�ut �+ i�l fb S �� !dC.�YNSS ►'z. _L2�J�2 �iZt, hC1YY)rU � <br /> ��Pek-Z. ^r sin s, ri Cen-�'ene<< rtsh�r, <br /> � <br /> ►.. ection Form Included: Q <br /> Comments Included: Q — ----- ----- -— <br /> Business Rep's Signature Phone Number ect a ignature _ Phone Number <br /> - - _ - — -- - -- -Number— 62081 -- <br /> INSTRUCTIONS ON BACK �orrect:10 Incorrect: X Al � ; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />