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Waste Tire Su .ay & Inspection Report* Inspection Report Number _I <br /> `kb <br /> T1 State B California111108468 <br /> CIWM6181(New0"(",) SurveyForm- Paige 1 I <br /> califomia Integrated waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r, Inspection Type (Fill one) <br /> Site Suffix: 3 g Jr @ Routine Q Re-inspection Q Referral Q Observation <br /> Local 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 /> Physical Address ` LA`6Sv A1-11 <br /> L_o3\__-_IA. � <br /> Straat <br /> Inspection Date <br /> City Stete ZIP Code Time In O Time Out <br /> 0 AM <br /> Business Rep Title <br /> It <br /> I AM I <br /> 71 ;;i_ <br /> c�i I `I !5 ; ® PM I � ' I� � I ® PM <br /> Operational Status Tire Type Business Role Storage <br /> P YP 9 Type <br /> Tire Count (Whole/PTE) L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> V D ® Active ® Passenger ® Generator I* Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> --- - - Q inactive Q Truck <br /> o <br /> Longitude — I , I^ 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 /> 0 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 IENFORCEMENT STATUS <br /> V � A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of 1/iolation 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 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 EJCT) <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 I 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 Q In Compliance - No Violations <br /> ® Q Other: § JL.1 <br /> Comments <br /> c �C <br /> Inspection Form Included: <br /> Comments Included: gSilinAture: <br /> b.SBusiness Rep's ature Phone Number Ins Phone Number <br /> INSTRUCTIONS ON BACK [EjXjAjMjPjL1E1 1112131 62081 <br /> White C py:CIW B Yellow Copy:Operator Pink Copy.LEA <br />