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= Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> kib <br /> State of California Fff 10 8 6 9 3 7 <br /> Cgrated 1steMana a Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Surve • BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �� I � i �I � � � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �— If Referral,choose referral type(Fill one) <br /> Identifier: L-5� JOCI_ l,t;n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� Inspected By Inspector <br /> � <br /> Lf Llc S <br /> Physical Address An Esso � <br /> ;v,�- <br /> Street I V-7 <br /> Cq���(� Inspection Date I I <br /> City <br /> � Stata /_tP Code) Time In Time Out f <br /> Business Rep Title —� O AM j , r AM <br /> 1 ' -17/ <br /> io PM 5 % 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 /> f 1* Active Q Passenger O Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor A <br /> O Q inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENMR-CREME-\NT S7ATTUS <br /> V A HAULING AND MANI.E§,,T UIREMENT.S4 s Y a <br /> Q Notice Of Violation Q Extension, <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § g C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle f'- <br /> Q Q , 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB x <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) . .'` <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/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 C-ompliance - No Violations u'. <br /> Q Q Other: <br /> Comments <br /> �s(LIN)o j,��- lit T -11 P - �� t� of fe.C,ti,�Pill <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Z;Business Rep'pAignature Phone Number 61n tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corre : In meet: R A M P El. 1 2 62081 <br /> White Copy IWMB Yellow Copy:Operator Pink Copy:LEA &�A <br />