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Waste Tire Sur , -y & Inspection Report nspection Report Number ■ <br /> State of California 11 - 1140897 <br /> CI%B181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> PartA- Survey- <br /> Business Profile Inspection Details <br /> TPID- �*1 Inspection Type (Fill one) <br /> Site Suffix: ` f' �/ ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> L-nCieCo <br /> Physical Address �� � 4tlsj �E3G��`C fig <br /> te 3s-l �• /�e�in Sf <br /> Inspection Date � � � (� S � 1 <br /> L� nfr <br /> Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> tt O 3 O o PM y J • PM <br /> �0 1'V l-„,VtI°c�lhc.i,,wL �rce:--t•a f - - --- _ - . <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 /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 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 Q Trucking Fleet ® 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 HAPRC§ULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> 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 FX7) <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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments • 1 <br /> Inspection Form Included: 0' <br /> Comments Included: --- -- -—- / u ” -- <br /> Busi es Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON B Correct: Incorrect. ; Vi X L ; 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE ® ■ <br />