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Waste Tire ,rvey & Inspection :Rept Inspection Report-Number <br /> r:ae_ <br /> State of <br /> 81California <br /> (New0410.4)' Survey/ Form - Pa e 1 I 1 - 10883 0 2 <br /> California Integrated Waste Management Boa <br /> rtl J g . <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type (Fill one) <br /> Site Suffix: V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ ^ <br /> (GuA If Referral,choose referral type(Fill one) <br /> Identifier: � 1 _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> iness or Facility Name Inspected B <br /> ( �I _ .�;�eS a� �.^�^� I P Y Inspector <br /> Physical Address IVY, <br /> Street <br /> '^e Inspection Date <br /> L�v--60—(\ � �__� Time In Time Out <br /> City State [IP Code _ <br /> Business Rep TitleAM S ! AM <br /> { 12'I� 0PM I I O I� 0P <br /> . L Operational Status Tire Type Business Role Storage.Type <br /> (Fill one only) -(Fill all4hat apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 5 .Q <br /> �) Active 0 Passenger Generator 0 Outdoor <br /> ;O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> I—-- — - Q Inactive Q Truck <br /> 0 <br /> Longitude O Planned Q OTR Q End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking.Fleet Q Government Q Retreader Q Dismantler Q-Tire Derived Fuel <br /> ® 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 I 1 <br /> Part B - Inspection of Waste Tire.Dealer, Generator, Hauler and End-Use Facility ENFORGEMENT STATUS <br /> O.M IRAULING 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O. 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 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 DCT) <br /> Q O 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 C-IWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> Q 1 Q 1 Other: §L <br /> Comments A 11 Ay% <br /> o us <br /> t\ \ I oS� 0� ftt.Gls G <br /> F(kCk`% � S bSfrn 1i�eaf� S�nQ.I - <br /> Inspection Form Included: Q 5T7O�� &"twS <br /> 6AU�176Comments Included: QZ <br /> BB1VsII 's.6'ogitRture Phone Number nspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK7Copy' l <br /> Imeorreet: P L 1 2 3 62081 . <br /> Whit Yellow Copy:Operator Pink Copy:LEA <br />