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Waste Tire SL*ey & Inspection Repor : Inspection Report Number <br /> State of California I 1 - 1127498 <br /> MB 181 04/04) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey— - BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- - � Inspection Type (Fill one) <br /> Site Suffix: l C ® Routine Q Re-inspection Q Referral Q Observation <br /> Local1 .�^ If Referral,choose referral type(Fill one) <br /> Identifier: 5�� �O��LU Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �en oe_k� At& Cw np uA _ p <br /> Physical Address 3 Q I <br /> Es o�'o <br /> gSakS Inspection Date / 30 O <br /> Time In ` Time Out <br /> Business Rep Title ( 0 O AM (� Q AM <br /> a I L V PM a O �/ 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 5 I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f & Active • Passenger ®Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive j Q Truck <br /> Longitude — Q Planned Q OTR 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 Retreader • 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 Othe� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS I <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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 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 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 Q 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 /> Inspection Form Included: <br /> Comments Included: Q — -- — -- I <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK rCorr <br /> t: correct: i. � E A PL I 1 2 3 62081 <br /> White Copy: I Yellow Copy:Operator Pink Copy:LEA <br />