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rE Waste Tire Su y & Inspection Report Inspection Report Number <br /> kAClWMB <br /> State of California <br /> 181(NewSurvey Form - Page 1 I 1 - 1140683 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: S S 27 G - Q <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: StANI �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 5 LLQ <br /> Physical Address <br /> Inspection Date 0 Q ` <br /> Time In Time Out <br /> Business Rep Title rt, O AM O AM <br /> C <br /> {{ # • 3 0 PM 0 Z 3 O 0 PM <br /> o c.K l earvw„nr- PLW CvX/ - --- - --- <br /> Operational StatusI ire 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 /> 3 ® Active Q Passenger ® Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPs Q Hauler Q Indoor <br /> O i Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply)-- -t --- <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 te r <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <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 FTI / M / M <br /> 0 : 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 <br /> (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 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 <br /> in Compliance No Violations <br /> Q L Q Other: § L <br /> Comments --- <br /> Inspection Form Included: Q r <br /> Comments Included: <br /> Busin Rep's Signature Phone Number Inspector's SI re Phone Number <br /> INSTRUCTIONS ON BACK Correct.*. incorrect: X i"fes s2C21 <br /> ,.� 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y: <br />