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i 51 Waste Tire4vey & Inspection Reoft Inspection Report Number ■ <br /> ,o. State of California 11 — 1127922 <br /> Cgrated Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> -t A- Survey BLUE OR BLACK INK PEN <br /> iness Profile ;Inspection Details <br /> I PID- // �, _ Inspection Type (Fill one) <br /> Site Suffix: �� t� Q i® Routine Q Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: ►1 �v �ti IZ/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> t- a"iseM G;blras - 1 c7 { �,��,�,� ft,2t►�bi ilc <br /> Physical Address <br /> 7Oq,99 Giv,z P►r C-*"-') . <br /> n �'' Inspection Date i � 0 -7 � � 1 <br /> `LLI���C.Cti �/�/, `C���3� Time In 1 Time Out <br /> Business Rep Title 1 (DAM L� 0 AM <br /> 1� l O PM 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 le Passenger ® Generator ® Outdoor <br /> 0 ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - ® OTR Q End-Use Q Container <br /> Q Planned <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder '40 OtherI �G�✓��2L -TC <br /> -- - ----- - -- - ---fT_j <br /> - - <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 EXT) <br /> Q Q 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ' L <br /> L..spection Form Included: Q, \ r <br /> Comments Included:®j G1111°a✓ /Cti. -- - ar"[-w.,r-ez - -- <br /> Business Rep's Signature Phone Number ns ec or's Ig ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct 0- Incorrect X A <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />