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Waste TireMly & Inspection Rep. Inspection Report Number <br /> ia <br /> State of California '?CIWMB1811st(New Manag) Survey Form - Page 1 I 3 0 <br /> California Integrated Waste Management Board � � � / � � t <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j 'q <br /> � i – ' Q Inspection Type (Fill one) <br /> Site Suffix: /`—ll Q Routine (2) Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(-,r), Toca oif) COUn+ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I_ Oq►� <br /> Physical Addressj <br /> L1199 Cl*. <br /> Inspection Date 117061 <br /> I Street Sfic�c.1��o f CA �':.;ZO�a <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> [= <br /> lil O PM O PM <br /> C0 1 <br /> ( <br /> pratinStatosire Typa— - Bus' essRtorage <br /> Type <br /> Tire Count(Whole/PTE) OO (Fl one Fill all that aPPIY) Fill all that aPPIY) (Fill all that apply): <br /> Y) <br /> ® Active Q Passenger Generator Q Outdoor <br /> GP5 <br /> Latitude . — D Q Closed Q Altered Q Hauler Q Indoor <br /> ude -- —.. r.---l— _ D Q Inactive Q Truck <br /> Longitude – , I I I Q Planned Q OTR Q End-Use Q Container <br /> _ I I <br /> Business Type (Fill all that app <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 1� nb Qn J– <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 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§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 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/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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments `'�?C�Q Gt,C3 n <br /> insp ection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � \/ iI M�P l_ C 1 I� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />