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® Waste Tire Su@6y & Inspection ReporIG"Inspection Report Number <br /> State of California <br /> ClWMB <br /> I 1 1108420 <br /> California Integral dtWaste Management Board Survey Form - Page 1 <br /> Part A- Survey��441i)+I�Yyfl -- ----- p - _-BLUE OR BLACK INK PEN <br /> " <br /> Bus'ness':Proftle 461u+ <br /> Inspection Details <br />� <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L•, �r I t I � , � � L`--'t___iJ ItRoutine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �C' �\ ��('tC Li��, (;L: j {"{ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or.Facility Name _ Inspected By Inspector <br /> Physical Address �- <br /> Street Inspection Date f � <br /> l— Time In Time Out <br /> Cifv �_—State ZII'Cade <br /> Business Rep Title t - / r 0 AM -- Q AM <br /> QPM 0 P <br /> - - - - Operational Status Tire Type Business Role Storage Type I <br /> T (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)'I <br /> Tire Count(Whole/PTE) <br /> # a (F) Active Q Passenger Q Generator Q Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> au <br /> GPS }} ( Q Hauler Q Indoor <br /> • I <br /> -. Q Inactive Truck 9 0 ContainerLongitude QEnd-Use <br /> Planned <br /> I <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 Q Other <br /> -- -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 EXT) <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 /> QQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Compliance liance No Violations- <br /> I � p <br /> Q Q Other: § - <br /> Comments <br /> 1 — � �,1 � 7F C, t✓'�t'' Ili i %C -� ! f� ,' � :�C /`,-_i .i <br /> T <br /> Inspection Form Included: <br /> p Q. <br /> Comments Included: 0:; <br /> - - <br /> I Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A } '{P E 111_2E, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />