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Li Waste Tire Su. - ey & Inspection Report Inspection Report Number ■ <br /> State of California 11 - 1127905 <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ! 5 V , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �' ' If Referral,choose referral type(Fill one) <br /> Identifier: ��Y.t �� 6CA ►�n kAl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physical Address 0 1 <br /> fps /d , n J <br /> �lW 'p� l�-rc� ���.� �WUt.C,.I . <br /> ( Inspection Date � � ` Z— � 1 <br /> Time In Time Out <br /> Business Rep Title7 ®AM 7 ®AM <br /> J <br /> _ 0 0P f 3 QPM <br /> ` v�sfl�r lzr m y� Tire- T <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 /> ®Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered / <br /> Latitude <br /> GPS 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 ®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 /> j V A 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting.Requirements Date <br /> M / 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 /> 0 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 /> 010 Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included. ®I A - -- - d�'1 fG ✓ - - - -- -- L'�1•-Z P f'��' <br /> I Business Rep' Ignature Phone Number I s cto s Ignature - Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect: XI i r 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy. © ■ <br />