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Inspection Report Number <br /> , Waste Tire Su �y & Inspection Report` <br /> ���' State B California Il - 1141282 <br /> 181( ew 04104) <br /> California Integrated Waste 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: ` 3 6 o I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` �� If Referral,choose referral type(Fill one) <br /> Identifier: �C:� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((( Inspected By Inspector <br /> Physics Address 13 - I I C) l m Q <br /> �G a Inspection Date g -7 / v <br /> L �� ` ���� ` Time In Time Out <br /> Business Rep Title <br /> 00 <br /> hh ® AM > o AM <br /> � 1­,6 M&1� OPM 6 OPM <br /> -- - --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Active Q Passenger ®Generator i •Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility 1 ENFORCEMENT STATUS <br /> Q Q PRC A HAULING AND 11 MANI 51 -Wastea HaTIeRr R(eg sRa MENTiondS Transport of Tires Q Notice Of Violation Q Extension <br /> Q O 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 Date <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 1 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 /> O 0 Other: § <br /> Comments <br /> P <br /> r <br /> 7h� �110c.C.Al2 n o --- - - -A10 i -�1 S --oma_ .r o <br /> Inspection Form Included: J p 0[TO <br /> �/'� / <br /> Comments Included: Q --- -�"��1Oo-.-0 _ -_ C- ��--.-- <br /> Business ep's Signature Phone Number Insp4 t Si ature Phone Number <br /> ­A­MIIINAIS 62081 <br /> INSTRUCTIONS ON BACK e ncoirrect a F 1 ( 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />