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Waste Tire Su. y & Inspection Report Inspection Report Number <br />1: wS7: StatCIWe B California I 1 -1088349 <br />04104) <br />California Int grat dt81 WaseeManagement Board Survey Form - Page 1 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection Inspection Type (Fill one) <br />Site Suffix: 4( C� / LOI @ Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: ` 1, TQG 00-k rJI1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />s- /ole JCGt V-(V1C� .S i ` 3 q _ <br />rPhysical AddressF/TTc)/ 11jeKPLI 1� <br />Street7 <br />CA, q6RD&Inspection Date O l / U <br />State ZIP Code Time In Time Out <br />Business Rep Title , AM <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />0 Trucking Fleet <br />0 Car Dealer <br />0 Agriculture <br />i l�j <br />c7 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />C 0 PM <br />' <br />Operational Status " Tire Type <br />Business Role <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />0 Passenger <br />® Generator <br />0 Closed <br />0 Altered <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 Hauler <br />0 Inactive <br />0 Truck <br />0 <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 AM <br />O PM <br />Storage Type <br />(Fill all that apply) <br />0 Outdoor <br />0 Indoor <br />0 Container <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Collection 0 Crumb Rubber <br />0 Shredder ® Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments (\(�v(�L+iE 1n�{C���� Y1�f7C'iJ(�LIZr.: <br />J(k—r 'c�✓�CuC.l ifh ►.C�a �c <br />// J. <br />L) <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date m/m/0 <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />�vr re <br />ri <br />-✓'0_ 1((' / <br />Inspection Form Included: 0. <br />Comments Included: 0 Business Rep's S(g re Phone Number Inspect <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X�, V I E; A MIPI LJEJ 11 M23 <br />62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />