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Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> t[I State of California 11 1088460 <br /> CgratedWMB asteManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t a LA O $ 4 1 le Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local am If Referral,choose referral type(Fill one) <br /> Identifier: � l.t�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address q '�„/� ESCAO <br /> l�' <br /> Inspection Date "1 <br /> Time In Time Out <br /> Business Rep Title i0 AM0 AM <br /> 0 PM O b 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> o 19 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair S Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators $1 In Compliance - No Violations s <br /> 0 0 Other: § <br /> - 1 T <br /> Comments 1(� �nS� 1 �o�-U�� �5 �e� � N i0) <br /> �o v�b`� onS US (,scla� oT Con(. o, <br /> 1 <br /> - uc.l1� S NNli)`�� iv <br /> Inspection Form Included: 0 <br /> Comments Included: 0 1+f 3 T O 2Y <br /> Inspec s Si nature hon <br /> Business Rep's Signature Phone Number p 9 e Number <br /> INSTRUCTIONS ON BACK Co Incorrect:X �/ ;X A M�P ��� 111213 <br /> 62oa1 <br /> White Cop .CIWMB Yellow Copy.Operator Pink Copy:LEA <br />