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03210040SI4 <br /> Waste Tire SL' Ey & Inspection Repor -_Inspection Report Number <br /> ro>2 State of California Y ry I I 1086915 <br /> CiWMB grated ,(New oage Survey Form - Paye 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �— - �� Inspection Type (Fill one) <br /> Site Suffix: J 3 I, p� �III`"��J IIIA <br /> IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- , If Referral,choose referral type(Fill one) <br /> Identifier: S QoJoaqA�`n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name B <br /> Inspected Ins <br /> P Y_ Inspector <br /> Physlca Address I l Q ' LNn-ESQ-tJ. 0 <br /> Street y <br /> �A ** CA RS�O Inspection Date [0:TL <br /> City(, S—caN'e ZIP Code <br /> - IITime In . Time O—�ut <br /> �O'AM �Business Rep Title "' <br /> — IQ AM <br /> 10 <br /> mPM <br /> -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fillone only) (Fill all that apply) (Fill all that apply) (Fillall that apply) <br /> f f0 Active ® Passenger I* Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> - - - - - -- 0 Inactive Truck <br /> Longitude - , i I ( 0 Planned 0 OTR O End-Use 0 Container <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 ® Other T <br /> L - —N01.11 I. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation <br /> 0 0 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 1/iolations <br /> 0 1 0 1 Other: § n o ' <br /> Comments lid k 1n �( 14 Q(� fS �L_ _�� �� 1l)1.1 L WA nQ�-t�l <br /> 1 CA q <br /> _C__v • �J <br /> imovs 1��, s uNUs�e se <br /> Inspection Form Included: 0 /���� <br /> I�s�'Ly /V.VI / —� 09Comments Included: Q �[Business Rep's ur Phone Number �Inp oYs Signature Phone Number <br /> INSTRUCTIONS ON BACK Corre Incorrect: 62081 <br /> EXA1d4P 'L E . 1 2 3 <br /> White Co :CIW Yellow Copy:Operator Pink Copy:LEA ® . <br />