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Waste Tire Survey & Inspection Report ..Inspection Report Number <br /> State B California C't�p Form - Page 1 <br /> CIWMB 181 stew nage Survey ey g I 1 - 1143457 <br /> California Integrated Waste Management Board <br /> Part A-Survey ._ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 r r� Inspection Type (Fill one) <br /> Site Suffix: 7 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �- t If Referral,choose referral type(Fill one) <br /> Identifier: S 4n J �a Lki C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> lPhysical Address 3 1 - 0 1 &, EsAo <br /> Arrn4jofj QJ , <br /> LO�� /� cp�� Inspection Date g � 1 b / l 6 <br /> l� t Time In Time Out <br /> Business Rep TitleO AM _ I 0 AM <br /> • O • PM 0 ` 9 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude 0 ® Closed Q Altered A) NIA <br /> GPS N/p Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 40 Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FTI / 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 /> Q I Q <br /> 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 010 1 Other: § <br /> Comments kol1 -Jr%(,_ &rAr —' }l.a.- —�'1 �[2� Qer-JQC (in 4r)1'5 &A Q w(1,1 0) <br /> I Ok f S CO CKc fn. <br /> Inspection Form Included: <br /> �-z��•vA7 s (uM' �U <br /> Comments Included ® n s p Signatue Phone Number Inper�/ re a)huoneg----2J <br /> Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct_*- Incorrect X A M E1713 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop • ® ■ <br />