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® Waste Tire Su&y & Inspection Report Inspection Report Number <br /> a State of California <br /> CIWMB I 1 — 11413 3 3 <br /> California Int grat d1WastJe Management Board Survey Form " Page <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: LI <br /> �s S � � 1 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L C�)+� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I <br /> 1...__._: ._3....c .. -f1... _;. ..±.. Uu_..-...................................._......._...................._...._..... <br /> ......1 <br /> sr,et �_ l ( q <br /> I (LA <br /> �� Inspection Date t 1 <br /> 01 / / � <br /> _r+,, r�� Time In Time O_ut <br /> Saute Z/P God ( <br /> Business Rep Title i 1 0 AM <br /> J <br /> I 1 �r� l� r O AM <br /> l u� � (1 C V 9 � - 1 - i O PM I 0 PM <br /> _.. ._. _... __ I l ..._..-._. .-..?.._'..._.._._1 <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 /> The Count(WhC31elPTE) <br /> t <br /> 0 Active 0 Passenger 0 Generator 0 Outtloor <br /> O 0 Closed U Altert�d <br /> GPS Latitude 7_71 0 Hauler 0 Indoor <br /> l ( -,-... ..._,..__.-_-._ _Y... O Inactive 0 Truck <br /> Longitude 0 Planned OTR <br /> End Use () 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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULINGANDMANIFEST REQUIREMENTS <br /> _---- — 0 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 m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date �1 / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m <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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators p <br /> 0 In compliance - No Violations <br /> 0 0 Other: § <br /> Comments I <br /> G C ! fN ) r ( l ► <br /> e <br /> t I <br /> }� <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's SignaWra,:� Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre6 Incorrect: X <br /> ® White Copy CIW Yellow Copy:Operator Pink Copy:LEA <br />