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a Waste Tire SuSpy & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB1811 teManag4) Survey Form - Page 1 I 1 - 1140636 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- U - M Inspection Type (Fill one) <br /> Suffix:Site j tJ ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local _`� �1 If Referral,choose referral type(Fill one) <br /> Identifier: s OIL, I 10CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> 7 <br /> Physical Address SS 7 t ) / 4 <br /> Inspection Date ` v -7 <br /> A61*3lec_.c, C el <br /> Time In Time Out <br /> Business Rep Title �q O AM O AM <br /> C) l l ® 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 /> O Active O Passenger O Generator O Outdoor <br /> O ® Closed O Altered <br /> -GfS Latitude. Q Hauler -0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station 0 Hauler O Agriculture Q Shredder •Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 10 1 0 Other: § <br /> Comments Q <br /> /�r« <br /> p!/a1 of <br /> 3 �� -a / - ----- ---. <br /> Inspection Form Included: O i <br /> Comments Included: Q � <br /> Business Rep's Signature Phone Number pec6rs Signature Phone Number <br /> - _ - -- - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X �, �. 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE <br />