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..tA Waste Tire Sulty & Inspection Report �spection Report Number <br /> State CIWMB California I 1 - 112 7 5 0 5 <br /> grated Waste <br /> eManage) 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 Type (Fill one) <br /> Site Suffix: Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� CQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U 17-1 <br /> '^"^6 Inspected By Inspector <br /> Physi al Ad-dress un v�� � I Sn� - <br /> 9 A, <br /> , 1 C . Lou ,se- Av-e <br /> Inspection Date <br /> ►`1 C�vl-f CoA, C(f - 1 l l V <br /> Time In Time Out <br /> Business Rep Title I Q AM Q AM <br /> Z ® PM l ✓ 0 PM <br /> -- l 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 i ® Passenger ® Generator ® Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 AMAULING AND MANIFEST REQUIREMENTS <br /> -- - Q Notice Of Violation O Extension <br /> O O 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 O <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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Q -- <br /> siness ignat re Phone Number In t s S' n ure Phone Number <br /> INSTRUCTIONS ON BACK Corre t: /Incorrect: x � CX A� p L E - 3 <br /> 62081 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />