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nii Baste Tire Su�y & Inspection Reporl Inspection Report Number <br /> ..,. - <br /> �� State B California I 1 1141325 <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- e--1 O Inspection Type (Fill one) <br /> Site Suffix: 1 y I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (- �� � ���� � ���� If Referral,choose referral type(Fill one) <br /> Identifier: J 1 t" CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> nn ` <br /> PhysfcallIress3 1 - I CSS O al Gtn ScAo <br /> 3�3� �cnpesi�. l �w Sui��- <br /> I' <br /> Inspection Date / / <br /> hh �f7� <br /> CA <br /> Q��I( l � I ( ,� O Q <br /> VL✓l. ` J Time In Time Out 1 <br /> Business Rep �1 � <br /> Title 0 AM 1 S Q AM <br /> l:15 CA, <br /> � � PM � J � PM <br /> (Tv— <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 /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 4D Truck <br /> Longitude — 0 Planned 0 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 O Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 40 Other u4f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST IREQUIREMENTS <br /> Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 § 9 p <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 m / 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 III'0*ln Compliance - No Violations <br /> 0 0 Other: § L. _ <br /> Comments0106WIIun Apt A ih'6 A aAA?__ +061j)1N (AW 1 t \ I t <br /> no U l blI lon1 Os �c�ls �' Cc)flCe j(1 _ <br /> 6 tif Is f w or <br /> Inspection Form Included: 0 �_ A rn r <br /> Comments Included: -. — `D, -�O �V <br /> Usines p Signature Phone Number 1 sp�or' Si�gnatl <br /> rePhone Number <br /> INSTRUCTIONS ON BACK Corr ct: correct 62081 <br /> Copy:White Copy: W Yellow Copy:c:perator Pink Copy:LEA <br />