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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> • it State of Caafomia <br /> grated asteMan Management Survey Form - Page 1 I 1 - 1088418 <br /> Calitorma integrated Waste Management eoard <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- —7Inspection Type (Fill one) <br /> Site Suffix: ` 3 1 3 Ej4j 43 - Q le Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: G� \ vh / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J CJS^V Inspected By Inspector <br /> Pyficca\\�dtess,vv_� Acccsones ?j `� - 1 U AILonuc,Ai mbok-, <br /> 6�E 8 k�olma►� ��d <br /> Co, �5a�a Inspection Date <br /> sirC1� <br /> Time In Time Out <br /> Business Rep Title ^ (, O AM ^.1� O AM <br /> QPM ♦R ® ®PM <br /> </ Operational Status Tire Type Business Role Storage Type <br /> Tire Courft(Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' J ®Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> 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 i Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS__ <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation 0 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 <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 C)Referred I 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 - No Violations <br /> Comments I It�l�Y�ei 1n�Q(_�itll� ��e �?1�,�)S �U WII� 1►le �1t�M�.�17G1 C.)k,5 �Q7��% <br /> roc;1119 Uses AI!Tyy, jye? wheel p),) ler ;RecycJers 4try,t xt55 c 7-ye. •c�rxud <br /> SLI,_—j,Ye_S pwr_ kzee-0` -mmareo, -+MjZt kc <br /> bci Tim- haulers awt) Rec e �o vivi� z„s 40fc,. <br /> Inspection Form Included:Q <br /> Comments Included:Q (/ Y7�'�dr�/�I act-%'S-4673 <br /> Bu ness Re 's iqn re Phone Number Inspe or' ig` ture Phone Number <br /> INSTRUCTIONS ON ACK Co e Incorrect:X E X I A M�P I L�E( �1�213I 62081 <br /> re - <br /> ■ White Copy IWM J Yeuew CDpy Operator Pink Copy LEA �� ■ <br />