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Waste Tire SL. v -ir,y & Inspection Repo +spection Report Number <br /> State B California I 1 1088026 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PE_ N <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i T Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> �n,l,� �-�q <br /> Identifier: qU1� CD UI,., Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector ` <br /> Q.-et ars ALA+o A4a► r i _ <br /> Physical Address ( o k.r ►5t I G In LA e ca <br /> Street <br /> Inspection Date <br /> I Lod k CA 952ya I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM -� Q AM <br /> Q PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> l <br /> Tire Count (Whole/P `, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T f <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> -- O Q Closed Q Altered <br /> GPS Latitude � � Q Hauler Q Indoo <br /> _ O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply ; <br /> Q New Tire Dealer ® 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 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 Notice Of Violation Q Extension <br /> Q Q <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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / 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 1 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § - -- - <br /> Comments Ro�ctlrL2 1r15 �0CTOrtrS IS @ to OS }ed <br /> Aoorm. y1 u.)as- sed -t►res s4or _oma-slfr:_. �> U J Fadi lg mite_ <br /> s 1 a vak. C r � UJ <br /> 42e e- '* e -, <br /> ire els d . o v l c?yAon-s or oreal`s.. ncernP, lowli-111111111MI <br /> - - <br /> Inspection Form Included: QI 7 A _ T <br /> Comments Included: Q1 Business 1Re s Signaturel` / (�g 3 <br /> 1, t <br /> p Phone Number 1 or's Signatures Phone Number <br /> X —`- — J 62081 <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: ,�A L C I L 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: <br />