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f Inspection Report Number <br /> Waste Tire S,0 y & inspection Repo ' . ■ <br /> State f California _ 1 i V i ) 9. 7 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board _ „ _ <br /> --Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> tV <br /> Inspection Type (Fill one) <br /> `� Q Re-inspection <br /> ection Referral Q Observation Suffix: <br /> Local ( (� If Referral,choose referral type(Fill one) <br /> Identifier: v�( ( joQ L,{lr �. ��bL "' Q CHP Q CIWMB O.Complaint. O Educational Visit O Other <br /> Business or Facility Name v Inspected By Inspector <br /> (Physical Address t v I ae14 K , <br /> Street Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title �t O AM O AM <br /> Alla ���1(� - "� , m lopm m • m Q PM <br /> (i - <br /> �a � I <br /> Status Tire Type Business Role Storage T <br /> Operationalyp 9 Ype <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q) Active C) Passenger (D Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> O Inactive Truck <br /> Longitude - Q Planned OTR O End-Use Q 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 0 Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q.Hauler Q Agriculture Q Shredder (0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V . A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O i O 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 0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> tQ' Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§1;8459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> _.... ...... <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> --- --- _. . _ <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O O 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 O In Compliance - No Violations <br /> Q Other: § 1 _II I8 <br /> CommentsAai,�tC�f /r��js�C (Lrr 74't'a C`(tie, _AJ fo1100,1� ) <br /> -�YG� U� j'QY (/ICC U l�GC 4U.�,C -- <br /> [ W;Jm.,I�)aM -71rp { t/rel I {K✓; ys��0 e No In7 <br /> f <br /> 'r. 01 Q;M t t 5� V/J A U✓v , p f (��1 t �1. of °i to <br /> _ <br /> Inspection Form Included: <br /> Comments Included l ' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> iU/ — 111213 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: )(� �' ( 1.r It i ' 1 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />