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LFWaste Tire Su4ty p p <br /> L & Inspection Re ortoppection Report Number <br /> State of California <br /> kaC,WMB <br /> 181(New 04104) Survey Form - Page 1 Il - 1143480 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O I Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(�� J oa�u�r (;win Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> NO 1 s A40 <br /> Physical Address <br /> Q� C A �c)aAD Inspection Date <br /> Time In Time Out b <br /> Business Re Title 1 ®AM AM <br /> Rep 6 � Q PM l O PM <br /> C �W� �A - <br /> --- ----------- - - -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 6 14 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 -` ® Active ® Passenger 4D Generator ® Outdoor <br /> GPS <br /> Latitude O Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive *Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer *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 /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q ' Q PR - Q Notice Of Violation Q Extension <br /> C§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 / m <br /> 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 /> i 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 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 13\6W11 ftCA 06A <br /> S 1 o) <br /> Inspection Form Included: QQ uta' <br /> Comments Included: 0 — d Cf <br /> _ �0-�17�' <br /> Busin p s nature Phone Number Inspec is Signature _ one Number <br /> - -- <br /> I _ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ;fit A M P 1 : 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LE <br />