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ills <br /> Waste Tire S y & Inspection Repo Inspection Report Number ■ <br /> State of California m 11 - 1127683 <br /> CIWMB1811st(New Manage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- d / ' Inspection Type (Fill one) <br /> Site Suffix: ` I'll y, © O Routine Q Re-inspection Q Referral Q Observation <br /> Local f M f-� If Referral,choose referral type(Fill one) <br /> Identifier: � � �if�� �-�" L �J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address T t <br /> "p A7zLfn W' <br /> CL5( Inspection Date + ( 1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 9 <br /> AM <br /> ti ® ® PM © � O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) A (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> U0 Active Q Passenger ® Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 Q 14 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 /> O - <br /> 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 Q Other: § L <br /> Comments <br /> VI � '1S cyl- <br /> Inspection Form Included: O . <br /> Comments Included: Q �1511k_ <br /> 4Phone Number a r' S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i � p 62081 <br /> • �L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LE <br />