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.. C'. <br /> Waste Tire SuAy & Inspection Repo, Anspection Report Number <br /> .rpt State of California <br /> B Il 1143721 <br /> Cgrated Waste <br /> eManag) survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _ -_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O I Inspection Type (Fill one) <br /> Site Suffix: I J 7 • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q(1 J O u�(� C(�1A(1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business ar <br /> &514 <br /> FacilName Inspected By Inspector <br /> 116— /�Q <br /> Physical Address 3 1 - l f�C_n Crw eli f ) <br /> (A <br /> q G��� Inspection Date <br /> C <br /> y J Time In Time Out <br /> Busine s Rep Title O AM L 0 AM <br /> j�y Un� pLAn� kr.�n fnic i ' • O O is PM I I O PM <br /> Rv, V a enci� I� C��. L'001a. -- - - - - -- <br /> - - - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 41 Closed 0 Altered u14 <br /> GPS Latitude 0 Hauler 0 Indoor � <br /> 0 Inactive ®Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 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 ® Othern� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility l ENNof Notice OfViolation0 SoTATUS E - <br /> xtension <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 i 0 I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires D <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 <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 ® In Compliance - No Violations <br /> 0 ! 0 Other: § <br /> Comments ' r r <br /> �O1 We_S�_ arc, tnS <br /> ;Inspection Form Included: 0 <br /> Comments Included: 41, v - 74\_ <br /> - (Do -q&& 3MBusiness p's- ignature Phone Number Inspe r s Sig <br /> fYdnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X Lf;. XIhtiILj 1 `1 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />