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. i: <br /> Waste Tire S1,.. vey & Inspection Repoi . Inspection Report Number ■ <br /> e�>< State of California 11 - 1127927 <br /> CIWMB 181 04104) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey_-- BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection J Inspection Type (Fill one) <br /> Site Suffix: 30 LI �� l ® Routine Q Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SC1'\ '_-sI: iC:�iil� ���� CHP Q CIWMB O Complaint Q Educational Visit 0 Other <br /> Business or Facility Name ` <br /> n Inspected By Inspector <br /> Nr'dJsU �1��C�IY <br /> Physical Address - l 3 - 1 C� ( A 163c, A,1n1�v1 <br /> �_ i Gr Ct IVl � <br /> Inspection Date '7 I <br /> CA cf,500L <br /> Time In Time Out <br /> Business Rep Title ®AM ll�� AM <br /> • 0 PM V U 0 PM <br /> - - --- -- --- - --- - ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) ! (Fill all that apply) <br /> ® Active ® Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude j O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, enerator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS G <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 Other: § --- --..—._ <br /> Comments <br /> (inspection Form Included: Q <br /> Comments Included: I&I __ <br /> Busi s P's Signature Phone Number I s c r' S' nature Phone Number <br /> INSTRUCTIONS O AC [Correct Incorrect: i X i t 62081 <br /> 0 White Copy:CIWMB Yellow Copy:Operator Pink Copy.L A © ■ <br />