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= Waste Tire Solt vey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181 04104) <br /> I 1 - 114 3 6 9 2 <br /> California Integrated WaseeManagementBoard Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � D I Inspection Type (Fill one) <br /> Site Suffix: te Routine 0 Re-inspection 0 Referral Q Observation <br /> Local I nIf Referral,choose referral type(Fill one) <br /> LAI) <br /> n <br /> Identifier: 1 Dal !/ „ .,ni' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Busin ss or Facility Name �J l � <br /> II Inspected By Inspector <br /> 1' L COnCCdC_ <br /> Physical Address 3 O_ <br /> �q Ob 26vxvr1} Ave, ----- - -- - -- -��-xx- <br /> C� - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I 0 AM 0 AM <br /> ' 0 PM O PM <br /> clue_. r enc►s d u�rle r -- ,- - - - - - <br /> - — --— — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 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 40 Other ° <br /> lrUour- c- (Y A(hjaC Rr' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST 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 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 O -- - - - <br /> 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 !In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments rt'111'4W14�l-�+�1 <br /> L4 COL) Jr), <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's SI nature Phone Number Insp or's Signature Phone Number <br /> • ��_-�_ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect VI X fi !'�4 P 1 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />