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aE. <br /> Waste Tire Sui y & Inspection Report Ispection Report Number <br /> $�Z State B California I - 1140989 <br /> Cgrated 1st(New <br /> Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 3 a S J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -ib`' cj__,1 K 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J - Inspected B <br /> P y Inspector <br /> Physical Address J <br /> doe C!�. v6) cl,40rpv . <br /> Inspection Date <br /> L��C CA 9 sa Ya <br /> Time In Time Out <br /> Business Rep Title O AMj / O AM <br /> 3 <br /> `7 <br /> •- Q PM 0 1 ® PM <br /> -{Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) (� <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -.__...... <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice of Violation 0 Extension <br /> --- --- - ---._.... __._. <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 114 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orEXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities I <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> - ru lA'_T nc '�►^� -vim . - <br /> © v.w <br /> IInspection <br /> Comments Included: ®I �.YC.+� - -- - - - --L ��� (40-o.b <br /> LBusiness Reps Signature Phone Number nspector-s ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 'i \ E__�a P e 3 62081 <br /> Whi(e Co =il,::•. C-, ^;�r3tor Pink opy: <br />