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r <br /> Waste Tire Sui .ey & Inspection Report nspection Report Number <br /> ��WMB1California(New04104) Il - 1143626 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- [ q / - 0Inspection Type (Fill one) <br /> Site Suffix: ' S 1 (Q 5 lD I ® Routine Q Re-inspection Q Referral 0 Observation <br /> Localt t If Referral,choose referral type(Fill one) <br /> e <br /> Identifier: 00 J okI LA 1(1j()a�TO CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _S E LLC 0 _ /+� 2R �}, <br /> Physical Address 3 ) I (/ I ,/Ln Es� b <br /> WS \N . 1� <br /> Ste)J�0r,\ Inspection Date 3 � IS � I <br /> l Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> � PM � V 0 PM <br /> - - - - L -� ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> - ' - Active Passenger Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> o O Inactive Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O 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 I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)(T) <br /> O Q 114 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O 0 Other: § <br /> CommentsOKI�� <br /> Inspection <br /> O <br /> Comments Included: ' ` O a <br /> Business Reps Signature Phone Number Ins _ Phone Number <br /> - - - - - _ - <br /> �tonatur <br /> INSTRUCTIONS ON BACK correct:* Incorrect: A p � t � 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink CokLEv <br /> ■ <br />