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® jWaste Tire Suk .ey & Inspection Repork. Inspection Report Number <br /> State B California Il - 1127539 <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r7 _ O � Inspection Type (Fill one) <br /> Site Suffix: L� I* Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: �(�� � 11,1� 1,V1� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> lav a��� �► r�.i��.� 3 _ I <br /> Physical Address <br /> Win <br /> 15aos Inspection Date 1 O O 1 <br /> Time In Time Out 1 <br /> Business Rep Title 0 AM 0 AM <br /> .._, PM S PM <br /> J Q-0a Qcann_o_ _ 0.s_ -. - <br /> 0� (Fill one only) (Fill all that apply) (Fill all that apply), Storage Type <br /> Operational Status Tire Type Business Role <br /> Tire Count(Whole/PTE) f a 5 �J (Fill all that apply) <br /> �J 1 Active Passenger S Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive � Truck <br /> Longitude — O End-Use Container <br /> Q Planned OTR <br /> Business Type (Fill all that apply) <br /> Q 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 !I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other �f4,Ilu Saes wnd (�,��,>,r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q I Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / / <br /> 18459.1 Tire Pram ID Number from CIWMB m m <br /> O O 14 CCR§ - Program <br /> i (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> O O <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § .1 l <br /> Comments n 1 Ou'C��e �nSf 11- <br /> it <br /> Inspection Form Included: Q' <br /> Comments Included: 0 - __ <br /> & T"^ <br /> Busi ss Rep's Signature Phone Number Inspe?r's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect h� 111 <br /> 62081 <br /> ! � FI <br /> ® <br /> White Copy:CIWMB- ® ■ <br /> Yellow Copy:Operator Pink Copy:LEA <br />