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Waste Tire Sur vey & Inspection Report Inspection Report Number <br /> State of hCaliforniaIl - 1144007 <br /> CIW1B 181(New 04104) Survey Form A y 8 - Page 1 <br /> califomia Integrated Waste Management Board <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> Site - I 1 , H _ 0 Inspection Type 0( R onsp Q Q <br /> Site Suffix: L•� L Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �an L�,1 ,( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M 0\,kACk\ (\ W\\(,� <br /> Physical Address <br /> Inspection Date U <br /> Time In Time Out <br /> Business Rep Title 1 OAM O AM <br /> 1 d O le PM 3 3 O PM <br /> Operational Status Tire 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 /> 0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler • Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) — _— _ --_ <br /> Q New Tire Dealer Q Auto Repair *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 • Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> V Q - S Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 EX7) <br /> Q O <br /> 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 /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> Q 1 Q Other: § <br /> Commentsi I O� 6 --� C( <br /> V,OUji vn�It1 C, ��'��02��►��. o �owd C —�i�l <br /> LA 1310qA1177109 <br /> Inspection Form �nc <br /> ncluded: Q < L <br /> Comments luded: S — -- � �� -, ` <br /> Buslness Rep's Slgnatur Phone Numbers Inspe or's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect iG�; �:,,i E }� A M►� P j a3 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy: A 0 <br />