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Waste Tire Suey & Inspection Reporo Inspection Report Number <br /> State B California Il - 1108416 <br /> CIWM8181fornia /04) 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- / L f - Inspection Type (Fill one) <br /> Site Suffix: / I 31 / [�E Q Routine Q Re-inspection Q Referral Q Observation <br /> Local '�` If Referral,choose referral type(Fill one) <br /> Identifier: /CGA ( 'tip;` I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / - - <br /> •� , Inspected By Inspector <br /> Physical Address <br /> f afleei_7_6_jam- <br /> 4! <br /> Street 1 <br /> C , � Inspection Date � t <br /> State Zlp Code I Time In Time Out <br /> Business Rep Title QrAM I 0 AM <br /> 0 P La S 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 4(4 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude m Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - —1-1� . Q End Use Q Container <br /> Q Planned Q 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 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 Q In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments <br /> i._,6�t '�,�L � 4 a, t <br /> � , <br /> � r <br /> ? ' ,, f�r; 'r �' Gt.uls t� { ntl�l�� Vr ." a Ajo UD, arc <br /> Inspection Form Included Q ' <br /> Comments Included: Q -- -PROW <br /> ` - l� <br /> Business Rep's Signature Phone Number Inspector's Sign <br /> "p <br /> L,� <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X V I L X i A A�TP I El 1112131 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />