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Waste Tire SAW & Inspection Report 3pection Report Number <br /> State of California <br /> CIWMB 181ZN 04104) Survey Form - Page 1 1 5 -- 1 01 3 4 4 21 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile u Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r r I S 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:. ( �pQ� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name UInspected By Inspector <br /> (4 5F 1RQCya[AJ0_y Sock foh ��g I _ Q <br /> Physical Address tJL J-6hN_R�Az' __j <br /> (_30lg Loo <br /> Street Inspection Date <br /> CitLy State� ZIP Cade I Time In `J Time Out w <br /> Business Rep Title [a : [� <br /> EOOPM 0 AM <br /> 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> f� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) V <br /> 1 1 ®Active Q Passenger ®Generator Q Outdoor <br /> j 'CQ Closed Q Altered <br /> PSLatitude <br /> Q Hauler Q indoor <br /> -- — -- - Q Q Inactive Truck <br /> Longitude <br /> – <br /> 9 Q Planned Q OTR <br /> i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 Q Other 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 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § r <br /> CommentsT ornl <br /> llzVjt2S hbtc S -rt, (a �tr <br /> 1 S a � re �ni{I L�'1 l-QY��tC i, o f u sF-ge u cALl a i 6,L iho-f to),,a( Fled- Y cz ud <br /> jN. Pwlcasld, ogE. All usect a.kid waSfe. �'es are. Sh ih Of <br /> ►untie or less jo Por f lapld o n trucks w I+fi fha faces fipiapon o uct OUt-ve <br /> Inspection Form Included: Q Wei <br /> Comments Included: ®l 4itte Phone Number gnaPhone NumberBusiness Rep' #' <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: f 1l A M p 2 2 3 62081 <br /> White Copy:CIWMB _ Yellow Copy:Operator Pink Copy:LEA <br />