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Waste Tire Sul by & Inspection Report Inspection Report Number <br /> ES Cgrated 1(New 04/ Survey Form - Page 1 15 - 10 7 9 3 9 2 <br /> State of California <br /> California Integrated Waste Management Board <br /> Part A- Suryey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 6 D Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -- Q �, _1-1 - -� - — <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> TOY O -CJ4 <br /> Physical Address - Ci' / .> L//3 ,30%/✓i l�Ov.4 <br /> � Inspection Date / 0 d Q <br /> (� Time In Time Out <br /> Business Rep Title 9s n •AM AM <br /> 7 7 V O PM V Q PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <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 /> 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 ® 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 /> --- --. <br /> -- l <br /> 7PRC•r;,HAULING., N A IF ST R , ....E NT ,., .;; r,u., , ,p ,: .:.; _ I <br /> Q Q -- - Q Notice Of Violation Q Extensio, <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q <br /> §42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline, <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 E)(T) <br /> --- ---- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ----- - - - <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 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 In Compliance <br /> Q Q Other: § _ <br /> L <br /> Comments F-4j ��,� `ruJ1`'/ / f e,4,0 /� � <br /> �s-i. /v0 t/i h-���•v� - <br /> Inspection Form Included: Q 4-de <br /> Comments Included: Q <br /> Business Rep's Ignatu Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACKAA P ; 111-7 3 62081 <br /> White Copy: I Yellow Copy:Operator Pink Copy:LEA <br />