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001.01.0.4.002.4 <br /> r � Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of CalifornlaCrWM8 181 1 1088470 <br /> ow 04104) <br /> California Integrated Wastie Management Board Survey Form - Page 1 Il _ <br /> Sart A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I U I T I I Inspection Type (Fill one) <br /> Site Suffix: I +3 I L 1_ p I 1 O I 1 { ® Routine Q Re inspection Q Referral Q Observation <br /> 111 -111 <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: I . S6Ln 11 13 W <br /> �t 1 n. _ Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name "h t-1 <br /> Inspected By Inspector <br /> I _ � i <br /> �_Nac�cu�,— ���_Sc�n�-1— � I <br /> Physical Address � <br /> U ` I V <br /> 1• -- " --X2.'7►_Vv� o_LA ._ <br /> StrecInspection Date 1 I <br /> dy State uP Cr Time In Time Out <br /> Business Rep Title —� I Q AM . I 1 I AM <br /> c M I —� _ • ® PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> i l ` ®Active Q Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 16 Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet • Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder Q Other I i <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 Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements <br /> QQ 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required(or NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 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 o-t�- don <br /> ob VAo_ c cod/e!n <br /> N ��: — �►a- j� Coy ,>��ani_V�;nq a �s-f h�'►r c - -- 't�� httkL_ <br /> Inspection Form Included: Q n ] <br /> Comments Included: Q <br /> Bu ess Re s i ur Phone Number Inspe I's Signature hone Number <br /> �ncorre�cfi �INSTRUCTIONS ON BACK Cor ect: I E I XI ArMj F j L I E F 111,213 I 62081 <br /> White Cop CIWM Yellow Copy Operator Pink Copy LEA <br />