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Waste Tire S%ey & Inspection Re AftInspectionReportNumber <br /> State of California <br /> CIWMB <br /> 181 04104) <br /> Il - 1127696 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details J <br /> TPID- � r+� � � � _ O � Inspection Type (Fill one) <br /> Site Suffix: "� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S n �Oi LI1 f1 c IXA 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 J Inspected By Inspector <br /> A I1 Goack � 0.11JS <br /> _ <br /> Physical Address 3 1 0 1 Esso f o <br /> ��,�0 �,� gSadS Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> 0 a ' 0 O PM V 0 PM <br /> ,g k1\ �� C� --0 W -- Operational Status Tire Type Business Role Storage Type <br /> TireCountCount (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger •Generator 0 Outdoor <br /> 0 0 Closed 0 Altered w A <br /> GPS Latitude <br /> O 0 Inactive ® Truck 0 Hauler 0 Indoor / <br /> Longitude — 1 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) - <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber fI� (�(� <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other f 4tICL 1 f 1(AA40X1Vjer <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V-1 A HAULING AND MANIFEST REQUIREMENTS <br /> ® Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date® / MIS / 60 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 4k 1 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 11 � ����,��� 1. ( � <br /> - - -Rb_ IrIL �_L15� (�S+{lR S- 2 Ct l/t_ Wk 01.,'' _UJIa N-4_._-c <br /> nn <br /> 'I t _ T L C CCZ Ss l '� 1�0 lisle - 011 �rel J16C e" <br /> \U - <br /> 5 —�')IL c o mcs �Z p n Lt r(11�c�' : �l ( <br /> 1142 <br /> y <br /> Inspection Form Included: 0 <br /> Comments Included: ( I- <br /> �R i ss Rep's igna Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr ct: ncorrect: X E XIAMIPILIEI 1112] 620811 <br /> ■ White Copy CIW Yellow Copy:Operator Pink Copy:LEA <br />