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Waste Tire SuSy & Inspection ReporteInspection Report Number <br /> State of California Il - 1140947 <br /> California Integrated Waste Management Board ew 04104) Survey Form - Page 1 <br /> Part_A- Survey_ BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r , ® Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: "1t�9 r0fzL'�t�ter � Z�� 0 CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ° <br /> ?&oo <br /> 1 � Inspection Date / <br /> CA <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> Aly <br /> 0 ° e PM 3 L ® PM <br /> --.f-...-. -—-- - -- ------- 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 /> 9 9 (0 Active 0 Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck I <br /> Longitude0 End-Use 9 Container <br /> 0 Planned ® OTR <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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation 0 Extension <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 / m / m <br /> 0 0 14 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 or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <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 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> .a <br /> Inspection Form Included: <br /> Comments Included: `�'r/G ( :7CJ�✓ 7 v�� <br /> L Business Rep's Signatur Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect_( , � <br /> - A M 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: EA <br />