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k <br /> Waste Tire Su*ey & Inspection Repori Inspection Report Number <br /> State of California <br /> California tornia Ingrated'WastoeManagement Board Survey Form - Page 1 I 1 1086957 <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I V�U LO 5 J - [KII ® Routine Q Re-inspection 0 Referral Q Observation <br /> Locale `� v , 6MN If Referral,choose referral type(Fill one) <br /> Identifier: v Q CHP 0 CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L__L_o_6� UL - Q [�q <br /> Physical Address <br /> I '3a0 S - c t L) A-v_ - ( - <br /> Street <br /> Inspection Date If I b JI <br /> LL_oa ti _ Com_ �Sd�ID <br /> City State ZIP Code Time In —�—I Time Out <br /> Business Rep Title I Q AM I -� Q AM <br /> OJ® PM �� I I� . ® PM <br /> � \ Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ® Active ® Passenger IS Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> 0 O Inactive 10 Truck <br /> Longitude - O Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler 0 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 HAUL{NG AND MANIFEST REQUIREMENTS 0 Notice Of violation Q Extension <br /> Q 0 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 /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> QQ 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 <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O• O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No 1/iolations <br /> O O Other: § <br /> Comments <br /> 4� ����� <br /> Inspection Form Included: Q <br /> Comments Included: Q - - <br /> Business Re_ i nature Phone Number Inspecto s ig tur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C� rect• Incorrect: X A M P !L - 11[,2131 <br /> White Cop :CIW Yellow Copy:Operator Pink Copy:LEA <br />