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Waste Tire 5ui Jy & Inspection Reppenspection Report NumberState ■ <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1140787 <br /> CIWMB 181(New nage Y <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> Ip_ � � _ O I Inspection Type (Fill one) <br /> Site Suffix: U 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: an-To of P CWfl(f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ES+e()So (,\ L�g�sk� �s n c, 3 9 o f <br /> Physical Address - &� Est ogo <br /> tiubv Pe.����,� s d A�_ --- - - ----V------ <br /> f Ul. Ck lszoq Inspection Date , a 0 I I <br /> J 1 Time In Time Out <br /> Business Rep TitleO AM O AM <br /> ' Q O S PM c) • PM <br /> - - - - -- - Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f j�J Q Active Q Passenger Q Generator Q Outdoor <br /> p 0 Closed Q Altered <br /> GPS Latitude A, 0 Hauler Q Indoor <br /> O Q Inactive Q TrucK/� <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> .. New Tire Dealer Q Auto Repair Trucking Fleet 0 Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler 0 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 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 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date , M / m <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 i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 11 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 <br /> ® In Compliance - No Violations <br /> 0 0 Other: § - 1 _ l 1 J <br /> Comments In�� ALAI fG iL3 <br /> A(.)5 fL <br /> 1 Utf'�US�rcy�,c�, o C14A) 5 (A U,0 <br /> ection Form Included: Q Me <br /> Comments Included: 1 ) Cj <br /> ( �Business Rep's Signature Phone Number Inspect Signature CNumber <br /> - - - - - - - -- - - <br /> INSTRUCTIONS ON BACK Correct:* incorrect: <br /> i X P .L62081 <br /> - -- -- t - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />