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Waste Tire Survey & Inspection Report Inspection Report Number <br /> 19¢11.- State of California <br /> California IntCWVMgnat 181(Neew 04/04)Management Board Survey Form - Page 1Fil - 108-691 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( al n/ DOl 51 l � - Inspection Type (Fill one) <br /> Site Suffix: O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa n) J Q 1 GlAfifil Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> P P <br /> L—S u,J_�es ' �I - 0 <br /> Physical Ad ss � I I L _E3c0 <br /> S ISD – <br /> Street <br /> Ls _0 � on G qsa Inspection Date IIII� } IIIA _I <br /> City - Spate ZIP Code Time In Time Out r <br /> Business Rep Title 1 0 AM <br /> ` , �� ' _7 IO 0 P LL3 ' IU�O I ®PM <br /> -Ci It - � b� "-" -: -" ��- 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 /> .. ' Active Q Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> Q Inactive Q Truck <br /> Longitude - I Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) Fj } - <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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EXE <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 • In Compliance - No Violations <br /> Q 1 Q Other: <br /> Comments „ p- <br /> ol_ o�s_o-r_�r��tsf Co OWt�- J <br /> �1.�e,'—�, �►- Mo��►,nl��►_. �tl -- ��ccs-Fol'����5 0.�r�_fc_.m_u�S 1���- ir�S ;� <br /> Inspection Form Included: Q `� <br /> Comments Included:® - <br /> Business p's Ngnature Phone Number Inspe or's Signature Phone Number- <br /> INSTRUCTIONS ON BACK Corre t: I jEjXjAjMjPjL,jEj 11J2 3 62081 <br /> WhitCopy: I M Yellow Copy:Operator Pink Copy:LEA <br />