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== Waste Tire Su, vey & Inspection Repoi _ Inspection Report Number <br /> LC.3_ <br /> State California I 1 - 1143580 <br /> CIWMBB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> ___-- BLUE OR BLACK INK PEN <br /> --t A-Survey_ <br /> iness Profile Inspection Details <br /> r'ID- Inspection Type (Fill one) <br /> Site Suffix: I 5 G 3 l l 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ban �) UAV'� 6CL41 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> Phry�slca Ad ress \ <br /> �.dInspection Date <br /> `�" ' � �� Time In Time Out <br /> Busipss Rep l` Title ) O AM O AM <br /> r�f-MVI �Z� hv'j H&P,, ! ® PM ® PM <br /> lc&r - -- —� Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger 0 Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Q End Use i Q Contytlr <br /> Longitude - Q Planned OTR �� <br /> --- -- ----- -- ---- ----- - QCT <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q 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 /> Q Service Station Q Hauler Q Agriculture 0 Shredder - Other - <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> !-A- IN <br /> - - <br /> V ' A HAULING ANDND MANIFEST REQUIREMENTS <br /> Q Q Notice Of Violation Q Extension <br /> Q <br /> 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: § <br /> Comments <br /> _spection Form Included: Q <br /> Comments Included: QI - / 7� <br /> I Busin Rep's Signature Phone Number s e or i ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NI , E X A M P l l 12 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />