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Waste Tire ,drvey & Inspection Reps. i Inspection Report Number ■ <br /> State California Il - 1143725 <br /> CIWMB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details -- - -- - --- - <br /> TPID- � O � � � - � � Inspection Type (Fill one) . <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �! Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> lit �J O tt_f) &t�L�� <br /> Business or Facility Name Inspected By Inspector <br /> T' Ce, SG its _ <br /> Physical Address) 3 1 [ I &,r) _5co <br /> Inspection Date <br /> -�r0.�n C �53b� <br /> Time In Time Out <br /> Business Rep Title <br /> - �- - - - --- - --- --- -- V C <br /> AM(&,A owocr - 3 T0PM � u G <br /> QPM <br /> Operational Status Tire pe <br /> 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 /> Latitude <br /> O • Closed Q Altered "/d <br /> NlA ' <br /> GPS iNfA ' 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 /> Q New Tire Dealer Q Auto Repair ® 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 <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 A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 /> 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 /> O0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments t <br /> r - <br /> Inspection Form Included: Q CZd9J S-n13Q <br /> Comments Included: * g/! V -(� <br /> u mess Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X "� v I E X A MIPI LJEJ 11, 12 3 62081 <br /> White` C - - - -- ® ■ <br /> Copy: IWMB Yellow Copy:Operator Pink Copy:LEA <br />