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Waste Tire Survey& Inspection Report Inspection.Report um erState ■ <br /> a�II. CfwM(California Survey Form - Page 1 1 5 - 1 0 7 9 1 6 1 <br /> CIWMB 1a1 Waste <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey _ <br /> Business Profile Inspection Details <br /> TPID- f D / Inspection Type (Fill one) <br /> site suffix: ( *Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier, SAS �OW►q,ye,'» - n/7Ys Q CHP Q CIWMB .Q Complaint Q Educational Visit Q Other,• <br /> Business or Facility Name Inspected By Inspector <br /> L des. �'d ode ti G.�T�_.4 �4Lf 3 g _ / o ( <br /> Physical Address <br /> I /850/ 1/ll•_ a,J-Y-*V-d <br /> Street <br /> Inspection Date <br /> City � tats e ZIP Code TiM <br /> e In Time OufBusiness Rep Tltle : 0 PM [:E <br /> 'm0 AM <br /> 0 PM <br /> _ Operational.Status Tire Type Business Role. Storage Type <br /> Tire Count(Whole/PTE) I , I 2 v I (Fill one only) (Fill all that apply) (Fill all that apply)- (Fill all that apply) <br /> I .__: a Active ®Passenger •Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude W,L_ _ _ Q Hauler .Q Indoor <br /> l Q Inactive Q Truck <br /> Longitude, I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair. Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 /> V A I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation .Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§429156-Registration/Decal in Vehicle _ <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / MiFfl - <br /> 0 <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O — ---- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I*In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Apowrrw)C,— - 0-oa �F;zD;..:-s_Ft�.'���, SP�.Lc.�;�►,E. A*-k <br /> 01 <br /> Inspection Form Included:Q <br /> Comments Included:Q - — 2� �°�� `J-'^""'Q — <br /> Business Rep's ignature Phone Number Inspector's SignaturePhone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect:7QOX�(% I I E I X I/1 M I P I'L ! 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> l <br />