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i Waste Tire Su_ y & Inspection Report ispection Report Number <br /> State B California I 1 - 1140840 <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- d / Inspection Type (Fill one) <br /> Site Suffix: t( Y `� I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> �t LJ-G(� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> ?P Y Inspector <br /> Physical Address J — ` /7 6o4 v 5 e, 13eef c4,— <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ` y O AM f Q AM <br /> v <br /> O / 0 •PM a � 7 � ® PM <br /> til -- <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 ®Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude � Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use p Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer •Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> I <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 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / F7 / 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 0 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 O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 1 Q I Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: 0 62-0e, 1/4 9.7049 <br /> Bus Re Signature Phone Number nspector's Signature Phone Number, <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X i A�m1f- I LX 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />