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Inspection Report Number <br /> Waste Tire Sur „ay & Inspection Report <br /> Ali State B California I 1 - 1143715 <br /> Cgrated asteMana 4) 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- L Inspection Type (Fill one) <br /> Site Suffix: t l l 4D Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: vCl l� S �cb� 1► t �F�G� _ / — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �J (— Inspected By Inspector <br /> �ck V1 -, se rvi-Physical "A' rress ` I Al 1Sp j <br /> _ L J Inspection Date /� / t <br /> Time In �j Time Out C <br /> Business Rep Title O AM O AM <br /> ,Cn ,Yvn t Z : d O PM Z 1-1 -7') ® PM <br /> �I C' 6au �-_t - --- R&+C[. ?Yl let i"W& 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 /> Q Active Q Passenger a Generator ®Outdoor <br /> O Q) Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O End-Use Q Container <br /> Q Planned OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> I <br /> Q Notice Of Violation Q Extension <br /> O O 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 <br /> M / m / m <br /> O O 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 /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 1010 Other: § <br /> Comments <br /> Inspection Form Included: 01 <br /> Comments Included: ® / "'"�' J?/�� "r ��!�-tQ-/ - o�d�Z- (� ✓-- �C 6 7�- <br /> Business Rep's Signature_ Phone Number _ p o s, i nature_ Phone Number <br /> INSTRUCTIONS ON BACK CI Iorrect: Incorrect: ! VA M � I L_I r_' T f J 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />