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=rani_ Waste Tire Survey & Inspection Report . Inspection Report Number <br /> 66[CL State of California <br /> RIM CIWMB181(New04104) SurVeV FOr111 Page 1 I1 1086987 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey' BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- I I I I Q 1 �/ C _ O Inspection Type (Fill one) <br /> Site Suffix: I / I m (9 Routine Q Re-inspection Q Referral Q Observation <br /> Local Q If Referral,choose referral type(Fill one) <br /> Identifier: V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I Pa- [ij-- K�h% 1 - oPhysical Address <br /> 11 8 81 E_ - Al_�ka_ S� I <br /> I <br /> Street <br /> Ist CL in'l- C+ �q /l� Inspection Date <br /> V I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Eo:,D( • �® PM I ® PM <br /> ju <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> I <br /> GPS i Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – I i iJ + Q Planned @P OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I <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 (ja Other — L_/ V uA►�� ,""'" '"`\ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V M 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 E)C7) <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 Q Other: § l <br /> Comments lei LYS- L 1l/�S wrE%C� lL�l PS _7(_4� �I t <br /> YVi-D_IP fi. �,Ioy1RaD s hd- <br /> Inspection Form Included: Q <br /> Comments Included: Q G <br /> B ness Reps _gna_ ,re ,,jPhoneNumber Inspector, ig iature Phone-Nu ber <br /> INSTRUCTIONS ON BACK C rest: )( a IM P L E 1 !2 3 62081 <br /> correct: <br /> White Co y:CIW Yellow Copy:Operator Pink Copy:LEA <br />