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i _ { Waste Tire Sui y & Inspection Report 'nspection Report Number <br /> EUi State B California 11 - 1127876 <br /> Cgrated asteMana a Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Su ey__--_ __ BLUE OR BLACK INK PEN <br /> Business Profile - _i Inspection Details - <br /> TPID- // Inspection Type (Fill one) <br /> Site Suffix: 3 b 3 Z - C) r 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> Local ��� �_ �� j If Referral,choose referral type(Fill one) <br /> Identifier: SLAM yt 0 CHP 0 CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address U /���✓LZ�' l �CJc.. r' <br /> Inspection Date <br /> 5+�cac� CA 95��s1' i <br /> Time In Time Out <br /> Business Rep Title _ ®IMAINA <br /> O PM 3 0 - 0 PM <br /> K Fir �rvYu�r rrn Operational Status Tire Type Business Role Storage Type <br /> WholelPTE <br /> 1 Ire Count (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ) Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> O Q Inactive 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 0 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 ®Other jaL,,, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ 0 Notice Of Violation 0 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 m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <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 EXT) <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 0 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 1 Q 1 Other: § <br /> Comments <br /> r <br /> Inspection Form �nc <br /> ncluded: 0 <br /> /l2Cci! 0x zrr _ -- <br /> Comments luded: ® � pT <br /> Business Rep's Signature Phone Number I ctor's Mature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X J 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy. <br />