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{ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> =fi„= State of California I 1 - 1144011 <br /> ew 04104) <br /> Califomialntegrat d1WasteManagementBoard Survey Form - Page 1 <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L, Inspection Type (Fill one) <br /> Site Suffix: 3 `7 3 —1 © ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalScu-170UtvAA^ <br /> , If Referral,choose referral type(Fill one) <br /> Identifier: wnin Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name --"— <br /> `n� <br /> -TC <br /> ` Inspected By Inspector c�c�vLa�n - <br /> Physical Address <br /> MCk Y\ , GA `1 )IS 7 Inspection Date Q <br /> Time In Time Out <br /> Business Rep r,� Mn Title I O AM O AM <br /> P1 )t \ VU``� --I J S OPM - � �—� - QPM <br /> - ------- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) tl (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> I0 Active Q Passenger 4j Generator ® Outdoor <br /> Latitude <br /> 0 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q End-Use Container <br /> Q Planned Q OTR <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 FacilityENFORCEMENT 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 /> (Required for NOV or EXT) <br /> Q 1 Q 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 I 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 1del a -�71_ _ 1� tZL��✓�T (1 t'M!�(� 7 <br /> u1Li�,,,,; n <br /> G 01 �o C1'% CIS ct�i -CA-s (1+ L00ce-rl). - <br /> Inspection Form Included: <br /> Comments Included: ?sif� <br /> 1✓ Q—t" �31 <br /> ss Rep's Signature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect , �/! I~ A M $ t 3 <br /> - - -- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />