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Waste Tire Su, itey & Inspection Report Inspection Report Number StateB 81California (New04/04) Survey Form Page 1 I 1 - 1144008 California Integrated Waste Management Board Y - J Part A- Survey....... - BLUE OR BLACK INK PEN Business Profile Inspection Details TPID- Inspection 1 Inspection Type (Fill one) Site Suffix: V J 4b Routine 0 Re-inspection 0 Referral 0 Observation Local t If Referral,choose referral type(Fill one) Identifier: S(/+A ��(� C��n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other Business or Facility Name 1 Inspected By Inspector Grn ��i�'aS f u�i n �n�,. � _ U Physical Address � ) 3 l � ESQ �Gt 1 b � � A �� Inspection Date � � I D 1r,.�.i1� I11t Time In Time Out Business Rep Title l / AM O AM (J V 0P QPM - ---- ---- - - --- Operational Status Tire Type Business Role Storage Type Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) 0 Active 0 Passenger 0 Generator 0 Outdoor O 0 Closed 0 Altered N/A N/,4 GPS Latitude NlA 0 Hauler 0 Indoor O 0 Inactive 0 Truck Longitude - 0 Planned 0 OTR 0 End-Use 0 Container Business Type (Fill all that apply) 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS V A HAULING AND MANIFEST REQUIREMENTS 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline 0 0 PRC§42956-Registration/Decal in Vehicle 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance - No Violations 0 0 1 Other: § Commentsk 11L� c �? , m i 13A01 41RA +Nl_ ._ IN _ u1)1 o tau i��0 j -Scccs_ COn(af)-- - Nt �� _ -ck �'s 00 1,0e T )n 145;