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Waste Tire S��✓ey & Inspection Repo Inspection Report Number <br /> State of California <br /> CIWMB 181( e14) Survey Form - Page 1 I 1 1088002 <br /> California Integrated WasttManam <br /> Waste Manageent Board i <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile ; Inspection Details <br /> Inspection <br /> TPID- Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �J Qh �nU l lr\ CC),Un <br /> y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M uv <br /> Physical Address IL3L(I ' LOLI <br /> Street I..�F6 / �2 U <br /> Inspection Date r <br /> 5� 0k CA q�2: 13 , <br /> City _..P State ZIP Code Time In __._—._.., Time Out <br /> Business Re Title AM <br /> AM Q AM <br /> o \c E _: EL' M L_E1 : 1 O PM <br /> rl - — , <br /> � - �� OperatLj ional Status Tiype ' Business Role Storage Type <br /> (Fill one only) (Fill all that a[#piy} (Fill all that apply) (Fill all that apply) <br /> QActive O,Passenger,' ® Generator Q Outdoor <br /> Altere <br /> Latitude 10 Q Closed Q d ; <br /> GPS Q Hauler Q Indoor <br /> _. ® Inactive Truck <br /> ��_... O <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V HAULING AND MANIFEST REQUIREMENTS <br /> A � <br /> Q Notice Of Violation Q Extension <br /> 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 Q14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> ----- <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> — <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 /> 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q § Y q <br /> Q Q Other: § <br /> Comments ) <br /> )<QIrl-x._-Ar, Qcc �Ion c or_ eG� -this cicjC 7NCc �� � : _ Ini� / WC_0-_ <br /> r�o £d_' mac tl, - �I�,��, rtt�S �or was-�c -ar�re_ reo ova\ � c , o - <br /> o�c,er ab..Ero-}c sj-�e lines �. e -tITCL; clre Si <br /> Inspection Form Included: Q ) � <br /> t Number 9rls ecto 7a :,% f <br /> Comments Included: Buslness Rep's Signature Phone _g - �t'! j <br /> Q g p is SI nature PhoneNumber <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: �A ?���y P <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> L <br />