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�t- eee. Waste Tire Survey & Inspection Report Inspection Report Number <br /> LEState of California <br /> CIWMB 161(New04104) Survey Form - Page 111 - 1088446 <br /> California Integrated Waste Management Board I <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- --I - ---- ---- �---- Inspection Type (Fill one) <br /> Site Suffix: - i <br /> L� 3 16 0�3 I ' I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I —� If Referral,choose referral type(Fill one) <br /> Identifier: I � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` -l�J r \ ~-w V Inspected By Inspector <br /> L_10n i Address— <br /> �_�,r V\.cc�ec�cl Yl �''� -I ��q �t-�So ��1 <br /> Physical Address 5 I L <br /> --- <br /> Street <br /> Inspection Date II / I d `� / d_ I_( <br /> eitl State 7h e <br /> — "- - —" --- �O"" I TimIn _ Time Out <br /> _ <br /> Cr. _ <br /> Business Rep Title / i 10 AM i I O AM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / 0 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 f *Active Q Passenger !Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � - 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 0 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 ® Other LM_ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORC►EM�E'-N"T�STATUS� <br /> V AI HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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/C^IWMB 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 1 Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: • Y <br /> Business Rep's Signature Phone Number Inspe for I ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Go eet: -orrect: E X A M P L E 1 Z 3 <br /> White C y:CI Yellow Copy:Operator Pink Copy:LEA <br />