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�!�ste Tire S4&ey & Inspection Repo Inspection Report Number <br /> BCalifornia I 1 - 1088369 <br /> CIWMB 181(New Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Business ProfiletY - Irrs`. on Details -BLUE OR BLACK INK PEN J <br /> TPID- 111") U 15 I(`( I t� ( Inspection Type (Fill one) <br /> Site Suffix: I I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / { If Referral,choose referral type(Fill one) <br /> Identifier: ;1 �D(1l�,bt �.f mil Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address V ' I " G1��,41 <br /> Jj ����.1111 r <br /> Street f x <br /> L-`,��h ✓.� � �/- ��O Inspection Date <br /> { 7 <br /> State ZIP Code I Time In ( Time Out <br /> r- <br /> Business Rep Title 0 AM • � O AM <br /> 0 P � ' _ , QPM <br /> 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 Q Generator Q Outdoor <br /> Latitude O '.® Closed Q Altered <br /> GPS �� • Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply-y) <br /> Q New Tire Dealer Q Auto Repair Q 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 /> Q Q Q Notice Of Violation Q Extension <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 O 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 O 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> b(i(a t Ylf �I5 �'(Gt .,� ���-�' .� Lpt j J 0 .tFo r . ��0C frf�, 6 <br /> a, r�'� � Fbrr L_ cr SE k Cyw? f� i4 not �c� -/C lc� � . 1 <br /> y <br /> I.nspection Form Included: ° 11( <br /> Z-'toinme is Included: Q }/ � p g;! <br /> Business Rep's Signature Phone Number Ins ector's I nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X F. .X'A M 'i 1. 1112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />