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�e Waste Tire Su ly & Inspection Report Inspection Report Number <br /> Of son State California I 1 - 1141013 <br /> IWMBB 181( e ) Survey Form - Page 1 <br /> California InteCgrated WasttManagement <br /> Waste Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i _ r Inspection Type (Fill one) <br /> Site Suffix: J <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -J <br /> Inspected By Inspector <br /> P1l'. 5 0 <br /> tl I ;n5 <br /> Physical ddress <br /> Inspection Date C, C 3 / l <br /> Time In Time Out <br /> Business Rep Title 1 0 AM 0 AM <br /> 0 P C) 0 ® 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 /> ®Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility F ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- --- Q Notice Of Violation Q Extension <br /> O 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 M / <br /> m / IT] <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 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 1 Q 1 Other: § Ir <br /> Comments n 1 <br /> KOI.�.k�'VI,R� i�1S�2C,C�itlrv��'�YYv�.Q� rct►A �i-S- GxCt�- <br /> Inspection Form Included: Q <br /> Comments Included: * _' A —S_ k& __ _ �Slgna <br /> Business Re Signature Phone Number InsPhone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E-�:X A L E ' 1, 2131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink <br />