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Waste Tire Su, .ey & Inspection Report Inspection Report Number <br /> CIWMB81'fornia <br /> (New 04104) Surve Form - Pa/uye 1 Il - 1143483 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey -- —_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> O 5 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: JG� Jam' J�� �( �Y� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LAS �;,� �3 9 <br /> Physical Address <br /> _ Inspection Date / O <br /> Time In Time Out <br /> Business Rep Title J O AM O AM <br /> ® PM 0 PM <br /> LYU� 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 ®Passenger ® Generator 40 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR ja End-Use e Container <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 /> 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 /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators b In Compliance - No Violations <br /> 0101 Other: § <br /> Comments <br /> .Inspection Form Included: !'. <br /> p ®' k_,', •� U`� ''y`� x��z�y�� X67-3 <br /> Comments Included: — <br /> Business 's Signature Phone Number sp nature Phone Number <br /> f- -- - --- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect E; 1112 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />