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Waste Tire Surgy & Inspection Report inspection Report Number <br /> State B California I 1 - 1088165 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI - <br /> Site I 2 I I I ^ I - I r I Inspection Type (Fill one) <br /> Site Suffix: Il _3 �+ �J 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> LocalU(l� If Referral,choose referral type(Fill one) <br /> Identifier: S Q h To Q qj, y J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v Inspected By Inspector <br /> u � � Lod► 3 q ' - I G t <br /> Physical Address <br /> I 3 Z�� E. K�ft\-eman <br /> Street Inspection Date Q � / o t1 � C) 8 <br /> I L_oc11 CH 9�Z. `-la i <br /> City State " ZIP Code Time In Time Out <br /> Bus�'yyt�ess Rep '` Title Q AM Q AM <br /> kctvl0 Radd(Q QPM <br /> i f�R.rl <br /> ca�►C11 �� Q�C1R..lr I Q P M <br /> Operational Status Tire Type Business Role Storage Type <br /> VireCo7un=(Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Coun <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> I " 0 Closed 0 Altered <br /> GPS Latitude I I • I I Q Hauler Q Indoor <br /> 0 Inactive 0 Truck Pill, t'V4' N/A <br /> Longitude - I I V 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 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 <br /> M / M / 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/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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> No � ►�e� C'c =;SCD C, ar - ;t 4e ,AI ►r haVe \,Qcf) ('&Y'icLbeG1 - <br /> ��ru���n� are r\0 `or)n'P_r 4h1:, - Vac..at i o n . Fra'LlI J V)CA�' <br /> rnavea t . r1CIt,1 o S�eC 6Alna o,a* ;;�r� E . Y-10\ .2rllcar, Lf7 L-Odi LA gr ZLI(�_ <br /> J <br /> Inspection Form Included: V' <br /> Comments Included: _ - <br /> 0,Business Rep's Signature Phone Number In or s Signature <br /> _ �(_, ��. • <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ji�. 'rX I A MI p I L I EI 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />