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Waste Tire Su, y & Inspection Report ..spection Report Number <br /> State California Survey Form - Page 1 Il - 1140732 <br /> CIWMB <br /> 181(New y <br /> California Integrated Waste Management Board <br /> Part A- S-.Irvey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � G Inspection Type (Fill one) <br /> Site Suffix: 1 3 L g :7 / o ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: .J" p-c',� C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name UU Inspected By Inspector <br /> lle oKec- f�,,L w. L;nu-S q <br /> Physical Address 3 / o <br /> SLI(. 3 l earn 1Gc c �cS. �w�ct <br /> q Inspection Date '8 Z .S o <br /> S -t-o cAe_t_c� C L S Z/ S <br /> Time In Time Out <br /> Business Rep Title AM / 0 AM <br /> � <br /> St� G � iti crr O 0 PM / 3 c) 0 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 b ® Active Q Passenger ® Generator Outdoor <br /> O <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair S 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> �Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ----- -- — - -Ate atti- <br /> r J <br /> -- '-t . 3 -/UO v r o I cL;cvv­� o-r c,� P-� cn,-i ce r✓-- <br /> O, iY1S�Cl ?OYL. <br /> Inspection Form Included: QX <br /> Comments Included: q <br /> - - CZa50 44-9--o4 Z3 <br /> Busin s Re 's Si ature Phone Number nspector's Signatu Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BA Corr ct: Incorrect: X , ( X A� L 1 11,1213 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />