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i$ Waste Tire Su :y & Inspection Report•Inspection Report Number <br /> State of California I 1 - 1140585 <br /> Cgrated 81st(New <br /> Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> .Part A- Survey - BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> � _ � / Inspection Type (Fill one) � <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: ' "(Z �v�. 10 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> II <br /> U <br /> Physical Address <br /> ZS s ec s+ Luriw, Z S <br /> Inspection Date f C 2- <br /> CA <br /> l2 <br /> 0r Time In / Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 1 -3 Is PM S ® 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 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck tj JA A/�A- Ali A <br /> Longitude - 0 Planned 0 OTR l 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 'lew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> sed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS T <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956- Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date'm / m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days _- <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 ! 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0;Referred i CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> I& In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> oq <br /> I, ,tion Form Included: 0i Ile <br /> Comments Included: ® cg'ol <br /> z_ <br /> Busin s Rep's Signat hone Numberspector's Signature Phone Number <br /> 1IItCOt I eGt - - - - -- <br /> INSTRUCTIONS ON BACK "Oc"ini 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copl.LE. <br />