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�' Waste Tire Sey & Inspection Repo* Inspection Report Number ~i <br /> ' WIN <br /> State CifiSurvey Form - Page 1 � .. 1 3 - -1 0 �1 06 <br /> Staten CaliforniaCa f New 04104) <br /> California Integrated Waste Management Board <br /> Business Profile inspection Details <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: . l q C� 2 - } (9 Routine Q Re Inspection Q Referral Q Observation <br /> Local ) If Referral,choose referral type(Fill one) <br /> Identifier: ayt �„�t .�r(Yt (` ,(�,) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> I o G( %((e �( v1/ic �.. <br /> Physical Address <br /> I ll f W1141a- I <br /> Street <br /> Inspection Date <br /> I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m ' m O PM m ' m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D ~ l.f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Q Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude m , Q Hauler Q Indoor <br /> O Q Inactive GTruck <br /> Longitude - Q Planned Q OTR Q End-Use ? Container <br /> Business Type (Fill all that apply) <br /> Q 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 Q Other <br /> I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / m <br /> Q .0 14 CCR§,18459.1'(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q .0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire.Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 6CR§18459.3-Retention of Manifest Forms and Tire 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 In Compliance - No Violations <br /> Q Q Other: § <br /> CommentsoZ,1(' Pj en" fir t`�,�e d <br /> 'S Cblcb-it bvillj�L4L'11' cd, C4 0�so —1 <br /> -7 ret z It r Wit=r „ �r i' t r� W G <br /> Inspection Form Included: .01, _ <br /> Comments Included: Q Business Rep's Signature Phone-dumber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect_X I �', �;� ,L <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator, Pink Copy:LEA ®' ■ <br />