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■ <br /> ® Waste Tire Apr4ey & Inspection Rep' Inspection Report Number <br /> -- State of California <br /> d= ; <br /> CW <br /> Me (New 04/04) Survey Form - Page 1 I 1 1088294 <br /> California Integrated Waste Management Board y g --- --- - - - - ' <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> -_ <br /> "on <br /> Business Profile <br /> I <br /> _ � <br /> TPID- ) �;' % y + I�U Z ' - Q I l� RoutioType (Fill <br /> Site Suffix: <br /> Routine Inspection <br /> inspection Q Referral Q Observation <br /> bI � -- <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S G n TUGt� I. t t rl �.0�1 n j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> _..._._T r��c-k_ -T'Physical Addre3�s <br /> HLKIrllej Ave. <br /> Street Inspection Date , f / <br /> I Time In Time Out <br /> c;try State Z/r'Cocte ...- <br /> Business Rep Title O AM ; O AM <br /> ' O PM O PM <br /> c _ i <br /> �b Operational Status re Type Business Role <br /> feStorage fy <br /> t <br /> /I (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that <br /> ®Active Q Pas�eng�r 0Generator Q Outcl ap <br /> Latitude <br /> 10 Q Closed Q Altered <br /> GPS ! Q Hauler Q Indoor <br /> •�- ---` �- Q Inactive Q Truck <br /> O <br /> Longitude - Q Planned Q OTR Q 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® OtherrU k Tire t�V <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 li <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 <br /> Q I 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 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 i Other: § _ <br /> Comments _ n - <br /> K <br /> WCI-Ac Ire 4C)y-C j C)Y)- trr}c Fc1ct`t1.t u_e r'ctr,r!0rLTl re <br /> rPfr"-jVa I - CTL r,- r:ttc_�` have rbc?-�.n re-#ctlrcd re_._ <br />{ Gv1-1 ca�G on r� to � Nay I o�- �s ln_,_ or c•YeG� o c on cern . <br /> Inspection Form Included Q^ <br /> Comments Included Q Business Rep"s'Signature r Phone NU <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: v I L ' ,1 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />