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03217040004 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> eer_ <br /> State CaliforniaSurvey y Form - Page 1FII - 108695 4 <br /> CIWMBB 181(Newew04!04) ("� <br /> Callfomia Integrated Waste Management Board `�J' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I S D (� 5 "+ I IJ 0EI — ® Routine Q Re-inspection Q Referral <br /> Observation <br /> Local r- If Referral,choose referral type(Fill one) <br /> Identifier: n �n (Dune Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Esckl I _ <br /> I b n _Ie.M�e-� loll <br /> 7t� <br /> Physical Address 3g J1 IB 0560 0 <br /> L �Cf05 M. ,�Dt,t�r —�V c - I <br /> Street y <br /> rr-S1 On (,A Inspection Date O b g Fo I C 11 H <br /> City State ZlpZo 3 Time In Time Out <br /> Business Rep Titlef �j J� 0 AM []�] �AM <br /> r _ /+ 1 t Iv .® PM [1--7 <br /> (a PM <br /> L� -`-'--- 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) pS <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> - - - '0 Q Closed Q Altered NIA <br /> GPS Latitude Q Hauler Q Indoor <br /> -- - - -- -- - Q Inactive Q Truck <br /> i <br /> Longitude - + I Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 ®Other <br /> �mun�ac�u,r�n I <br /> Part B Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 M=AULINGA D MANIFEST REQUIREMENTS <br /> Notice O Violation Extension <br /> Q Q <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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Bate <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 E�X7) <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 Refer►ed/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 1 Q 1 Other: § _ <br /> Comments <br /> Inspection Form Included: Q A. (P,21 6 Q1.1_-2 17Q <br /> (��O <br /> Comments Included: QOfL - 7 ���� - <br /> Bus ess Rep's. Signature Phone Number Insp tot's Signature 'Phone Number <br /> INSTRUCTIONS ON BACKCor Incorrect: X A m P L E 1 2 3 62081 <br /> . White Copy. IW Yellow Copy.Operator Pink Copy.LEA <br />