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AWaste Tire Su. ✓ey & Inspection Repon. Inspection Report Number <br /> State of California <br /> Form - Pa1 I 1 - 1143695 <br /> California Integrated Waste Management Board J J <br /> Part_A-Survey --- --- - --- _ _- — _ --. _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - � Inspection Type (Fill one) <br /> Site suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: SO,n l �tif l (�E�/t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> CC�MC <br /> GI <br /> Physical A dre s <br /> ( ( Inspection Date C] <br /> / 1 <br /> Time In CJ Time Out <br /> Business Rep \\\J Title 0 AM 0 AM <br /> -7 <br /> ! o PM 19 PM <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 /> *Active Q Passenger I*Generator ® Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <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 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 ® 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 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 <br /> d In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> I <br /> Inspection Form Included: Q <br /> j Comments Included:® f Lt2P <br /> - �3-- <br /> siness Signature hon Number n eCt nature Phone Number <br /> -- - <br /> INSTRUCTIONS ON BACK Correct. _ Incorrect X 1N/! _ � 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />