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I U+$2117040008 <br /> UZERWaste Tire SuS my & Inspection Repor, TIn1spection Report Number <br /> Califofornia . <br /> rnia IntegratedCWaState of lsteeManagement Hoard Survey Form - Page 1 ( + yY 1086 <br /> 9 9 8 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L-LbD / r Inspection Type (Fill one) <br /> Site Suffix: �lL y 6 D <br /> ( 1 ®Routine Q Re inspection Q Referral Q Observation <br /> -15J <br /> Local M If Referral,choose referral type(Fill one) <br /> Identifier: &A ALU a/, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> r �q <br /> Physical'I ress 3 - / o / I TT116wSO <br /> Street � <br /> I S-k� / , y' l Inspection Date <br /> City }t�, �� Stat ZIP Code I Time In Time Out _ <br /> Business Rep Title III `Q O AM I I O AM <br /> � I �- p aPM j ' � I ® 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 /> f ® Active ® Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude i , j Q Hauler Q Indoor <br /> _ _ _.__ - - :____O Q Inactive Q Truck <br /> I <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ,0.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 MENEGREEMENT 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 EX7) <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/C-IWMB 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 C-ompfiance - No Violations <br /> Q Q Other: § <br /> Comments <br /> �v�h Ia�C-1-`�t�S_� <br /> Inspection Form Included: Q p <br /> Comments Included: Q -- We <br /> �� — <br /> Busm ure Phone Number Ins&r',J�Sgn ture. Phone Number <br /> INSTRUCTIONS ON BACK Corr ct: ncorrect: Ex �a � � E x :23 <br /> 62081 <br /> White Copy. IWM Yellow Copy.Operator Pink Copy:LEA <br />