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Waste Tire SAW & Inspection Reportonspection Report Number <br /> �:: =jyj State B California 11 - 1088333 <br /> fo,� Cgrated Waste <br /> eManage) 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 /> Site - / _ 0 Inspection Type (Fill one) <br /> Site Suffix: ! V I I I / j O Routine Q Re-inspection Q Referral O Observation <br /> Local / r If Referral,choose referral type(Fill one) <br /> Identifier: Ton q ul Y 1 ( t;l,t 01� O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name 4 0 <br /> Inspected By Inspector <br /> Physical Address — <br /> 1 ( � S L l , is o4q .S� <br /> t <br /> k_P vi Inspection Date <br /> State ZIP Code i Time In Time Out <br /> Business Rep Title I I 0 AM Q AM <br /> 0 PM 0 PM <br /> _y <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator 0 Outdoor <br /> u Q Closed O Altered <br /> GPS Latitude i ( , I O Hauler Q Indoor <br /> u <br /> O Inactive Q Truck <br /> Longitude — I I , I I I I O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station Q Hauler O Agriculture O Shredder O 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 /> - 0 Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O Q Other: § - <br /> Comments <br /> ��1��. ��ar� iCi� v �xt _, � t,;lt: �tPIL � �PC ��hr���i►� �` C' OSP <br /> 1,4cl;✓ 7 �1 ��f�11 1�e /30�1S� -Dl. 7h�s reocr <br /> �5 ref la Q_ rer�o�->� 1-- 393 qq -b C l ar* Fv WI)Ich TPID# i's ' f[, <br /> r ' t?Lr� lit C�t�/n �t u i'_ - .- <br /> -� - - <br /> Inspection Form Included- <br /> Comments Included. <br /> Business Pro�.Slgnature Phone Number Inspector's S gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAf<I( ,Correct:* incorrect: X EX A Mit L(E, 11 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />