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09336050031 <br /> tt'L .Waste Tire Survey & Inspection Report Inspection Report Number <br /> „6 Stets of California <br /> 06 Survey Form - Page 1 I 1 - 1127546 <br /> CIWMB 187(New OMO4) <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- _T I�j I Inspection Type (Fill one) <br /> Site Suffix: I�� L6 L3�� 3_� F <br /> 1i I Is Routine Q Re-inspection Q Referral Q Observation <br /> r - -- —� <br /> Local ! (_JW1 I If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected B <br /> � P Y Inspector <br /> Physical 'Address I - I I Q I )- A <br /> Street r <br /> Inspection Date j I <br /> Lam* - - C�. 3�6, L <br /> Crty Sfate IJP Code Time In Time Out <br /> i <br /> Business Rep Title - I Q AM _J Q AM <br /> I' <br /> � l i • fc PLO0 PM <br /> i® l� . 0151 <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 /> 3: "f-'Active Q Passenger ® Generator ® Outdoor <br /> -Latitude I" -�� O ®Closed Q <br /> Altered <br /> GPS <br /> Q Hauler Q Indoor <br /> - <br /> l-- J- - - Q Inactive ®Truck <br /> Longitude Q End-Use Q Container <br /> •I ' i I Q Planned Q"OTR• <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet' Q'Government: Q Retreader 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 I® Other Azz 1 -- �- <br /> Part.B- Inspection of Waste•Tire Dealer, Generator,.Hauler.and End-Use Facility :ENEORCEAAENT STATUS <br /> 2V A. 'HAULING'AND MANIFEST:REQUIREMENTS r :0 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. ' <br /> Q Q PRC§42956-Registration/Decal in Vehicle Complianl;e'.Deadli'Z <br /> i"y'b <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB 0:1 <br /> Q Q• 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers p Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 --Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> e!, <br /> Inspection Form Included: Q ��-�/�y`�� <br /> Comments Included: - - <br /> Business Rep's Signature Phone Number Ins or's i nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK. ;CocWnpcorreqt:`�V V . JX AlIM P L White Copy. Yellow Copy:Operator Pink Copy:LEA <br />