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== Waste Tire Su aY p p Inspection Repo" Inspection Report Number <br /> State B California m 11 - 1143809 <br /> Cgrated Waste <br /> eManage 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: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SUSCbUflkJ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �e.\�� A uk u c cc e j S 3 y _ 1 <br /> Physical Addressrry� <br /> cA qJ�L� Inspection Date / 0 / I ]� <br /> J Time In Time Out ` V <br /> Business Rep Title 1 1 � Q 0 AM Q O AM <br /> ��(�1 V1 IU—• Ow4v'(- PM PM <br /> S�Q�^ Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 9 ®Active Passenger 0 Generator 9 Outdoor <br /> Latitude O Q Closed Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive It Truck i <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® 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-1—A-1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> M / m / m <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 Q 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 /> Q 1 Q 1 Other: § <br /> � r � <br /> Comments ,b t n f f ,�A(A,' 0 C <br /> my lto U(k C,S, <br /> u(1Cern <br /> woke-,- t \I-C-, i <br /> Inspection Form Included: Q �_Si <br /> CommentsIncluded: Q - - — -n ep's Signature Phone Number inspeca Phone Number <br /> u 62081 <br /> INSTRUCTIONS ON BACK [Correct.-* Incorrect: XLAI T 23 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE ® ■ <br />