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= Waste Tire Sur . ,y & Inspection Report inspection Repor, Number <br /> LEE <br /> Gu _ State of California <br /> CIWMB1811(New04104) Survey Form - Page 1 Il - 1127492 <br /> California Integrated Waste Management Board <br /> Part A- Survey___ __ -_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix_ Routine Q Re-inspection Q Referral Q Observation <br /> Local ` L If Referral,choose referral type(Fill one) <br /> Identifier: ISQ ��(,/� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ,(�,, Inspected By Inspector <br /> E-)P,q 6Ln <br /> Physical Address <br /> Inspection Date ` 1 0� Z C� <br /> La7f+l �C) <br /> Time In Time Out <br /> Business Rep Title O AM Ct Q AM <br /> ® PM O PM <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 /> 0 Active Q Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude j Q Hauler Q Indoor <br /> O Q Inactive ®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 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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> V A I HAULING AND MANIFEST REQUIREMENTS 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 /> 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 /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O <br /> 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 {} © ,' r Ir <br /> Cert-- <br /> Inspection Form Included: Q� <br /> Comments Included: 146F-1 g`vf <br /> Business RepsSignature C P Nu ber/ Ins c r' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect_X ] ►, p; ' 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy:L <br />