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_ Waste Tire #Wey & Inspection Rep Inspection Report Number <br /> ■ .11 State of California ■ <br /> CIWMB 181e ) Survey Form - Page 1 Il - 1140970 <br /> California Integrated Wastt Management <br /> Waste Management Board <br /> Part A-Survey —_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details J <br /> TPIDC- , Inspection Type (Fill one) <br /> Site Suffix: �� � � � l Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�� ` � _Com` �/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> i <br /> Physical Address 3 ct G ( Al 6,o Az!unk ,fC, <br /> C�}� a55�® <br /> Inspection Date l 0 5 <br /> L.c t t J (_ <br /> Time In Time <br /> Out <br /> Business Rep Title /r1 O AM 0 AM <br /> 1 V ' L) 0 P ' 0 Q 0 P <br /> - - — -- - - - <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 /> f ®Active (P Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Q Q PRC§ 2HAULIN9 AN51 -D MANIFEST aste TireHauler <br /> Registration( Rand <br /> MES 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 DateM / M / m <br /> Q I 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 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/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 ® ln Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> /r <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep s Signature Phone Number I t e S' tura. Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X P X A PIL 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />