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.fggg- Waste Tire Su -P%y & Inspection Repor Inspection Report Number <br /> State of California — <br /> CfWMB181( eSurvey Form - Page 1 I 1 1088430 <br /> California Integrated Waste Management Board i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> `� <br /> TPID- I Ill Inspection Type (Fill one) <br /> Site Suffix: L/ —_-- <br /> f Routine Q Re-inspection Q Referral Q Observation <br /> Local t (1_ If Referral,choose referral type(Fill one) <br /> Identifier: �� G�/"V\� /'vq.`f'u' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I -pv 60 I - <br /> Physical Addre s L,�j��] I a <br /> LI 01 V r `.��f"CJC� Lam' \• J I/��t.i /��J.-JJ- I ��V// <br /> Street <br /> Inspection Date <br /> City / ySlate ZIP Code Time In Time Out <br /> Business Rep Title �I � �� Q AM i�—� <br /> AM <br /> I s �I / <br /> �� ARr, <br /> i.� / ® PM 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 /> ' ' 1 D ®Active ® Passenger 9 Generator Q Outdoor <br /> --'- O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> `-- - - Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> i <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 /> 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 Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 Date m / m I 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 EXT) <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 Compliance - No Violations <br /> Q Q Other: § <br /> Comments <� "Vtes o <br /> V <br /> t <br /> �-S_ s m <br /> r►'''l �I P�� � r �� 1�1 ^�i1.S ,b � y <br /> Inspection Form Included: l <br /> Comments Included: Q <br /> Business Rep's ignature Phone Number Inspector's ignature• Phone Number <br /> INSTRUCTIONS ON BACK M7��y- <br /> 62081 <br /> X A M P ,� E; 1 '2 3 <br /> White Cop Yellow CopOperator Pink Copy:LEA <br />