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Waste Tire Su ey & Inspection Repor` Inspection Report Number <br /> State B California Survey Form Page e 1 I Il - 1088 3 0 6 <br /> gWMB 181(New nage) 9 <br /> California Integrated Waste Management Board t <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 u Inspection Type (Fill one) <br /> Site Suffix: L ILA I I*Routine Q Re-inspection Q Referral Q Observation <br /> Local �\ 1 r0 If Referral,choose referral type(Fill one) <br /> Identifier: ��f� l �ln lu _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name VVV Inspected By Inspector <br /> I '__11�l�S <br /> Physical Address — (� L <br /> XXXJJJ 111 <br /> QL <br /> 5trea' Inspection Date <br /> v�i Time In Time Out <br /> City SratE L.P Coo <br /> Business Rep Titler AM r^ 151 O AM <br /> s <br /> — — OPM �' ! � �� � � QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 I (Fill one only) (Fill all that apply) (Fill all that apply) —(Fill all that apply) <br /> 11Active Q Passenger 0 Generator 0 Outdoor <br /> 0 ] . <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive ® Truck . <br /> Longitude — I Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair. S 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 I _ I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORC_EM_ENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> Q Q 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 1 Q 1 Other: § _,( <br /> Comments TU-1\_ - o,f� ..0 ____QlAa CuntA 1__ D_.OUM-11 <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> 1 10 <br /> Business Rep's Signature ber Inspec�i's�Signature <br /> Phone Number <br /> INSTRUCTIONS ON BACK Co r*ec Incorrect: X M P L f ' 62081i 2 3 <br /> ■ White Copy: W Yellow Copy:Operator Pink Copy:LEA ® ■ <br />