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: Waste Tire Survey & Inspection Report Inspection Report Number <br /> Ba I �, 1088442 <br /> CIWMa 181steManag) 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: f -I l 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , '_') l Lm e6cul tzt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '� Inspected By Inspector <br /> Physical AddressG�( A l�ns� )�otb k_ <br /> ! 1 <br /> 1157 N - <br /> Inspection Date C CI Gl <br /> ��. 15M, Inspection t <br /> Time In Time Out <br /> Business Rep Title / * AM ® AM <br /> �- i CJ O PM t Q PM <br /> 4i vcl/4�' rlu�t- <br /> - - - —- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ✓ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q indoor <br /> o Q inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> - <br /> Q New Tire Dealer Q Auto Repair 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 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 O 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 /> 0 Q Other: § <br /> Comments '`('�%E- tj '"'r• t'-S C_41Z:l �CYI e d),t V(iS \CY__ Ct 6 <br /> ` lam -TD11txA.)� CJ CLS r V-'o <br /> Inspection Form Included: Q aG / <br /> 11 <br /> Comments Included: Q - - - <br /> Business s ST ature Phone Number Inspe or' Sig a e Phone Number <br /> INSTRUCTIONS ON BACK orrect:` I orrect: X � E,X A.M P L E 12 3 62081 <br /> Whit Copy.CIW Yellow Copy Operator Pink Copy:LEA <br />