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�i Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State B California I 1 - 1143463 <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey___.--_ . _ BLUE OR BLACK INK PEN <br /> Business Profile TInspection Details <br /> TPID- O r� � (D- <br /> ' Inspection Type (Fill one) <br /> �Site Suffix: a ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: SCA o J 00, w n Wun� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Q)m y s b1CC>e-k su vi �- - <br /> Physical Address 3 <br /> %S k4 1 " - �>`O 19.AW[l A V ei ---- - <br /> Inspection Date � � S <br /> S�de,12��� (CA �SZ� v h <br /> Time In Time Out <br /> Business Rep Title � � � O AM � � � O AM <br /> il�% Ub � V PM ® PM <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 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> D Q Inactive Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 'fVLt(,rL <br /> 1_ <br /> ® <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Other �1 t 1 <br /> �t✓k, �,Q1i r <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> — ......- <br /> j V A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Date <br /> M / m / m <br /> Q I 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive 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 /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q O Other: § <br /> Comments <br /> W,-� W4S Yl0 <br /> 'Inspection Form Included: 0 r <br /> Comments Included: ®! - -- <br /> Business p's Signat a Phone Number Inspe is ignatur Phone Number <br /> - -- <br /> INSTRUCTIONS ON BACK Correct: Incorrect. i 62081 <br /> � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :L ® ■ <br />