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Waste Tire Sui'y & Inspection Report Inspection Report Number <br /> State of California <br /> CWMB <br /> I 1 - 1141311 <br /> California Integral d,WastJe Management Board Survey Form - Page 1 <br /> Part A- Survey _ _- _-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: of 9 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �G1r2 ( C� � _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business�or/ �� <br /> Facility Name Edi Inspected By Inspector <br /> Physical Address 3 -7 - S u A&-o j Xie -:J✓� <br /> la 3 <br /> Inspection Date O 0 9 <br /> Time In Time Out <br /> Business Rep Title AM ® AM <br /> QPM � � PM <br /> �_ s <br /> - -- - -- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) I <br /> Tire Count(Whole/PTE) � (,� ® � (Fill all that apply) <br /> � � <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned OTR 0 End-Use • Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility LENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 1114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 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 ! 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!CIWMB Enforcement <br /> i <br /> 0 0 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 /> 0 0 Other: § <br /> Comments <br /> _ ��f�'es"� - G�� /� — �' -T-" fe,Gl.�O�e u✓c�¢e �.i''�-- � j� ly/ �,c.y'e mc <br /> Inspection Form Included: 01 9 <br /> Comments Included: 0 - - --- - - ----- <br /> Business Re Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corre t: I correct. X ' E!X A M�4 PL � III <br /> �L`�� 62081 <br /> White Copy:CI r. Yellow Copy:Operator Pink Copy:LEA <br />