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® Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> �» State B California Il - 1140631 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> t A-Survey _ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> PID- Inspection Inspection Type (Fill one) <br /> Site Suffix: S Routine Q Re-inspection Q Referral Q Observation <br /> Local5.) <br /> ' r If Referral,choose referral type(Fill one) <br /> Identifier: — Say oda L4,11n C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 ' t &((W f1► A . <br /> Physical Address <br /> gboo Howwrcl Sk_ - U��----- <br /> Inspection Date ' 0 <br /> S`}'oc,k�o n C A gSJ(3L <br /> Time In Time Out <br /> Business Rep Title ` O AM O AM <br /> ' I ®PM 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O * Closed Q Altered N N/4 NA <br /> GPS Latitude <br /> �� Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 40 Agriculture Q Shredder Q Other <br /> Part B -Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <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 / / <br /> 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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: § L _1 <br /> Comments � 1 d,1 lJ�tt-A, 1 1e-,. I n � r _ hl'6 ktee <br /> _­pection Form Included: <br /> Q <br /> Comments Included: '• <br /> •i Business Rep's Signature Phone Number Inspec r's�Sig�nature hone Num_ ber <br /> INSTRUCTIONS ON BACK `Correct:* Incorrect: + lit x A, �. 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />