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Waste Tire Atey p p& Ins ection Re or. Inspection Report Number <br /> CI ate of <br /> 81California <br /> 04104) I 1 - 114 0 8 0 0 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � C' � LA <br /> Inspection Type (Fill one) <br /> Site Suffix: b ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Q,0--jpd[j lLL11 f, Covn4 - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ��` � � ` Inspected By Inspector <br /> y cU39 <br /> Ph sical Address � � <br /> Inspection Datecka� c A I%rlr7 <br /> Time In Time Out <br /> Business Rep 1 l Title ' 1 5 e AMOAM <br /> O PM 6 5 O O PM <br /> ( G,d, 1 111 <br /> — — — —- -- Operational StatusTire 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 /> 64 ® Active ® Passenger 4D Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive S Truck <br /> Longitude — Q Planned Q OTR Q End-Use • Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 Q 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 /> Q QQ Notice Of Violation Q Extension <br /> 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§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / Fll <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q j Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 I 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �A. rl—o ku S ma, <br /> Inspection Form Included- Q' <br /> Comments Included: yy <br /> ® Z.se <br /> Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK - - <br /> Correct: Incorrect + r 62081 <br /> k 'V i <br /> p - -- - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:LEA <br />