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= Waste Tire Efey & Inspection Repo"� Inspection Report Number <br /> ■ -II: State of California ■ <br /> CIWMB 181California Integrated Was eeIManagement Board Survey Form - Page 1 1 1140739 <br /> Part A- Survey -- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l � � � � � � - © � Inspection Type (Fill one) <br /> Site Suffix: IS Routine Q Re-inspection Q Referral Q Observation <br /> Local (7 r. If Referral,choose referral type(Fill one) <br /> Identifier: SUn J Q(LC�Lk1 n WtJ(n� �J► Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` J Inspected By Inspector <br /> Physical Address CpV1 (A- <br /> �OtaC�p St . <br /> Inspection Date <br /> �A I <br /> Time In Time Out <br /> Business Rep Title lAM ® AM <br /> I S S QPM 1 1 3 5 © PM <br /> 0 Lt,-�1tJ'" <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 /> U j# Active 0 Passenger 0 Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 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 A HAULING AND MANIFEST REQUIREMENTS Transport of Tires I Q Notice Of Violation Q Extension <br /> 0 0 § g P <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments D ` I I <br /> r:1� <br /> A\Aj, AoA_AAri� uvs <br /> Inspection Form Included: Q '?Y941133 ( y <br /> Comments Included. 10'? `OJ <br /> Business R Lf Signature hone Number Insp tor's Signature Phone Number <br /> - - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X t �� - - 62081 <br /> --ll -_ - - <br /> XAM z <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LE <br />