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weA: <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> B State.of California <br /> B <br /> LB CIWMB Waste <br /> eManag) Survey Form - Page 1FI1 - 1088077 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - 1 3 I n ® _ O Inspection Type (Fill one) <br /> Site Suffix: t 11"� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � � O CHP O CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 4T Am <br /> L_132_o Perrrncx vl« I <br /> Street <br /> Inspection Date <br /> ��S�Zx�C l-a71 CC `Z,5a2C.YGb� I l <br /> City State ZIP Code Time In Time Out <br /> Q AM <br /> Business Rep Title Il ® AM I I <br /> jJ l I ' r QPM l C�-0] QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) '(Fill all that apply) ..(Fill all that apply) <br /> Tire Count (Whole/PTE) ; <br /> ®Active 0 Passenger ® Generator O Outdoor <br /> O Closed 0 Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> O <br /> Longitude — ( Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> i <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder Q Other I l <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A11HAULING AND MANIFEST REQUIREMENTS <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of olation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2=Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use.Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q 1 Other: <br /> Comments R t1ls�1>�h I 13 (JWY1C�tiJW_�_vl <br /> AL <br /> Inspection Form In uded: <br /> Comment I elude . <br /> ss Rep's Si a re Phone Number In for Si ature• Phone Number <br /> INSTRUCTIONS ON BACK Cor ct: I correct: 62081 <br /> E ?CANhP :L E! 1 ;2 3 <br /> White Copy CIWM Yellow Copy.Operator Pink Copy:LEA <br />