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■ Waste Tire Sui _ sy & Inspection Report Inspection Report Number ■ <br /> 'LEE <br /> EEi State of California 11 - 1141048 <br /> CIWMB 181( e ) <br /> California Integrated WasttManagement <br /> Waste Management Board Survey Form - Page 1 <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Li � U 5 J - C) 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` � If Referral,choose referral type(Fill one) <br /> Identifier: :t� �0 s✓1� i0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Phy6 Ad essSJ �ts r t I Ci�,J ►t�1� �� l�� - 1 [ J P7vCl!✓� <br /> l <br /> �r 53S--) <br /> Inspection Date q � Q 2 <br /> ���� Time In L Time Out C� <br /> Business Rep Title O AM j O AM <br /> ,,,( l J ® PM L 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 /> E E 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered I 91A <br /> GPS Latitude 0 Hauler i 0 Indoor <br /> O 0 Inactive • Truck <br /> Longitude - 0 Planned 0 OTR <br /> 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility � ENFORCEMENT STATUS <br /> _V 1-HAULING-AND-MANIFEST-REQUIREMENTS-- - — - -- — —- -_ <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 Lo Other: § <br /> Comments <br /> Inspection Form Included: 0 �v <br /> Comments Included: - - - --- <br /> Business Reps Signature Phone Number In for gnature - Phone-Number <br /> - --- <br /> INSTRUCTIONS ON BACK Correct. Incorrect A M F � 1 ; 2 3 62081 <br /> L <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />