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Fdd <br /> Waste Tire Sui :y & Inspection Report Inspection Report Number <br /> it State B California I 1 - 1127665 <br /> Cgrated 7steManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> --- ----- -- <br /> Business Profile Inspection Details <br /> inspection Type (Fill one) <br /> Site Suffix: y` K,1. `y Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` - If Referral,choose referral type(Fill one) <br /> Identifier: San �Ck.���y1 �-w►V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility NamInspected By Inspector <br /> �� l i� e'k� M06- �f��� C45+vxx�l� 3 <br /> Physical Address l� s <br /> 3 Cls- E . <br /> I (� Inspection Date 1 0 <br /> C(5RI5 Time In Time Out <br /> Business Rep Title /�"� �f AM 0 AM <br /> -] / J <br /> ,�. / L! � l QPM QPM <br /> T01),f7r1 C Garr � <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 /> ® Active ® Passenger ® Generator O Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 1 Q Inactive Q Truck <br /> Longitude - Planned — OTR - End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 7 <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) — <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities --- <br /> 0 0 <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®,In Compliance - No Violations <br /> 0 0 Other: § <br /> CommentsOavbhr <br /> i•��rDPC7�1� �� � �'! Tl�li� L3'-s //� <br /> No ak 16pl- <br /> Inspection Form Included: Q 73 <br /> Comments Included: <br /> usiness ep Signature Phone Number P Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I I ; I: A MIAL 13 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />