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im <br /> Waste Tire Sur,,.-y & Inspection Report ispection Report Number <br /> State of California <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 Il - 1140825 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 Inspection Type (Fill one) <br /> Site Suffix: 5 iZ 3 T / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: LV �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address Is / - i C <br /> Inspection Date I I <br /> Time In Time Out <br /> Business Rep Title / d 0 AM r2 0 AM <br /> 6. 0 PM � � ® PM <br /> n� !' l�x� ninceL <br /> �wtr - - - - - - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 07 / ® Active Q Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned ® OTR <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 Q Notice Of Violation Q Extension <br /> -- - <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 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 If In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: OI <br /> y <br /> Comments Included: ® - ��-�-y �Z�u'"`' !) y(�If—0 4_2_ <br /> Rep's Inspector's Signature Phone Number <br /> _ Business Signature Phone Number _ 62081 <br /> INSTRUCTIONS ON BACK Corre ncorrect: x �/ X A`' p J� E l l Z <br /> White Copy: W Yellow Copy:Operator Pink Copy:LEA <br />