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Waste Tire Su. :y & Inspection Report inspection Report Number <br /> State of CaliforniaCIWMB nit81 el <br /> California lntegratdWaseManagement Board Survey Form — Page 1 1141161 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile 1 Inspection Details <br /> TPID- x: n <br /> Site Suffix <br /> spection Type (Fill one) <br /> � � ( � � O I <br /> I _ f Q Routine Q Re-inspection Q Referral Q Observation <br /> Local '- _ If Referral,choose referral type(Fill one) <br /> Identifier: Y l^ <br /> �Qa �"� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ff Inspected By Inspector <br /> Sla —S <br /> Physical AddressL JOS 3o 's DTO <br /> I —3?0 � Q j <br /> 1 <br /> Street -�� <br /> 1 <br /> Inspection Date QM2 CA I <br /> O U <br /> State ZIP Code Time In Time Out _ <br /> Business Rep TitleO AM _— <br /> j (� <br /> (J T— � , ( •� , 0AM <br /> f I C -j1(`tel { f+ / V .. O PM I [ '� O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/ E) ; ,, <br /> Active 0 Passenger , Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> _ O Q Inactive Q Truck <br /> T_ <br /> Longitude — Q Planned O DTR 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 Ret reader 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 Q Other 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ......._........ __.._._. _ ___ Q Notice Of Violation Q 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. I Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> I <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O Q Other: § -- <br /> Comments t(de h�!e 5 -4'c -D 11 101 i , C%1 <br /> t t 5eS Ac 60 i f t far5,ervlce I d,( S,<=)GgJ of ttt 5. t b� <br /> IM Q +'4tAAAASV -P tN Pot • No tai 0 l ati, <br /> { <br /> Inspection Form Included: Q <br /> Comments Included: Q Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X i X1 A M p L E j 2 13! 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />