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iij Waste Tire Su. .ey & Inspection Report Inspection Report Number <br /> A <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 1 9 - 1 0- 7 9 3 0 0 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / 7 a / 7 r ® Routine 0 Re-inspection 0 Referral 0 Observation. <br /> Local /` If Referral,choose referral type(Fill one) <br /> Identifier: 5 o/pq .i77 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Q CCLL <br /> Inspected By Inspector <br /> Physical Address `� _ iC� t ,B{�7-7f1��tJ✓,� <br /> 1,,2_ey GG 61[x•4 14e' <br /> Inspection Date <br /> Time In Time Out q <br /> Business Rep Title �' AM 2 AM <br /> O 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 /> ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 001-lauler Vl�olndoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other ��r� /"C,-r� yvr.—f <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 0 1 0 Other: § — <br /> Comments !s�-'I L �,i�/'<rLt - �Lt�►/+ts� „� r�vc> `Cj� <br /> 3x21 S' a'C_C stt'aze_j - , CPO' s'�336 / ;^ ��r� <br /> e., <br /> Inspection Form Included: 0 <br /> Comments Included: 0 — <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK FCorrect:0 Incorrect: 01'�V/ f i7A M P E 3 62081 <br /> ® ` <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />