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i= Waste Tire Sur .ay & Inspection Report .Inspection Report Number <br /> State California I 1 - 1144036 <br /> CIWMBB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details _— <br /> TPID- 3Q <br /> I I _ Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local G��, � ,^, / If Referral,choose referral type(Fill one) <br /> Identifier: Z�l `�,/V� L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l � <br /> 3,qiD GJ. j�c,mme,, Ln ,�Oc GA '? 2t9 - <br /> Inspection Date � � � f'1 � Q <br /> ) <br /> Time In Time Out ` <br /> Business Rep Title ] 0 AM / 0 AM <br /> / ® PM G J� 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 /> 0 Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude o Closed Q Altered Q Hauler�/A Q Indoor ry/A <br /> ,1 <br /> O Q Inactive Q Truck /H <br /> Longitude - 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 f <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®OtherCj ���l�' <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i 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/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 in Compliance - No Violations <br /> Q Q Other: § f - ,ii <br /> Comments QLh�71/� rC"�) tZ <br /> �C fizz s oy-- -\ -_c �s �3 � 1 -t71 <br /> �,. ►�i_e-c-o_-v�-lrc — <br /> Inspection Form Included: Qi <br /> Comments Included: Q <br /> Business Rep's Signature Phone Numberc r' Signature Phone Number <br /> - -- - - - - - <br /> - 6208 <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect: \,X, (� �V) I E X1 A I <br /> ■ Pink Cod.L White Copy:CIWMB Yellow Copy:Operator ® ■ <br />