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== Waste Tire Su*E & Inspection Repo spection Report Number <br /> aeH_ <br /> State of California <br /> • BHHi.- Il - 11084 <br /> ii <br /> CIWMB 181fornia /041- Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ` I`-� L 3 v ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �—�— 1 If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �LuAd <br /> rD_ f u�c, 13 <br /> Physical Address <br /> Street PA <br /> Inspection Date <br /> City St'0ic Z/P Codc Time In Time Out <br /> Business Re Q AM <br /> p I - Q AM <br /> �e I _kU Sv <br /> O -- - -- '") �'L1 S.--SQ PM L— • I l- PM <br /> Title <br /> 40 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) u r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude � Q Hauler 11 Indoor <br /> 0 Inactive If Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use @0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 i I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation <br /> 0 0 0 Extension <br /> 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 <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 EXTJ <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 Q Referred/C-IWMB 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 C-orrpliance - No Violations <br /> 0 0 Other: <br /> Comments N-—k-J) 10 _i— =V-o �5�Ql �'�(/, A _ O A OW,Ln-- s— <br /> b1 b U O1- _loAS 6C b5 <br /> �— <br /> Inspection Form included: 0 V - � <br /> Comments Included: 0 - 'l^- 1 9 �L77Q-_ �o��Sign ssRep'sSignture Phone Number Inspature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co rect•. Incorrect: aC A P L I 1 i 2 3 <br /> White Copy CIWM Yellow Copy:Operator Pink Copy:LEA <br />