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�� Waste Tire Sudsy & Inspection Repo* p p <br /> �. Inspection Report Number <br /> State of California A I +"� <br /> r Cgrated 11teManage) Survey Form - Page 1 I 1 - 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ - _ BLUE OR BLACK INK PEN <br /> Business Profile 4 spection Detailsa <br /> TPID- In <br /> spection Type (Fill one) <br /> Site Suffix: O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> f Q CHP Q CIWMB Q Complaint Q Educational Visit Q OtherIdentifier: Q1 ;1 <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �C r�a Lk•���a ) . <br /> Physical Address <br /> Lt�rlS�l�`tr, i_�,cct�. I <br /> Street <br /> �A Inspection Date <br /> I 1 ri �r<�it �H 9 SS 01 Time In Time Out <br /> Cih, State ZIP Code <br /> Business Rep i Title AM AM <br /> O PM O 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 Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude � • _ Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — J Q Planned Q 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 Q 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 /> 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 / 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 t 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> C) k6V <br /> r <br /> CLCO T.1 <br /> Inspection Form Included: Q "9\ <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: XJ�, X j R,hT P i L I E i j I 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />