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!'Hi_ Waste Tire Sur ;y & Inspection Report Inspection Report Number <br /> kL <br /> State B California �y� I I 1 - 1086CIWMB 181(New 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- Inspection <br /> Inspection Type (Fill one) <br /> Site Suffix: 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Lsota_1_odq0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `��1 <br /> Ins ected By - InspectorMPhysiAdm 10011 <br /> ESCA <br /> --- <br /> Street O / O 9 / Ell <br /> ( �j(�� Inspection Date <br /> �— –^ v- 1-" Time In Time Out _ <br /> City Slate �rr't ode <br /> Business Rep Title (060& I t iS 7-p- <br /> PM "t I V 0 PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � ..Q <br /> ' ' U ® Active Q Passenger I* Generator 4j Outdoor <br /> J­ Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude – Q Planned ® OTR Q End-Use Q Container <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 ® Other [J�i(� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> MIM AND MANIFEST R00.1REM ENTS <br /> Q Notice Of Violation Q E <br /> Q Qxtension <br /> 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 / m m <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments ��_n2..,1 -U►_1C�!_1_ _-.V���1� _ �L'(1(���e—�_Q��V�.�1N�i..._I-' _ (� � <br /> Inspection Form Included: Q <br /> Comments Included: ®7BsianlCep <br /> s S at re; Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Co rect- Incorrect: r 62081 <br /> LEIXIAIMP 'L_ E1112131 <br /> White Cop CIWM Yellow Copy:Operator Pink Copy:LEA <br />