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*EII_ <br /> Waste Tire Su&y & inspection Repor Inspection Report Number <br /> site of California I 1 - 108831 5 <br /> Cgrated 1(NowW04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Suffix Site : I 15- Q �7 O[11 <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q� ��/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> Name /� � UH <br /> Inspected By Inspector <br /> Ph <br /> I I o 't/�_V a 11 S - f' � �ical Address <br /> T �\ ) <br /> Lf 3S E F �m,ovd- 0S t I <br /> Street <br /> J 'vC,k— l^ Inspection Date D (,,, �i FDCity ( [,/ ` l/ I /State ZIP Code Time In Time Out <br /> Business Rep Title - O AM Q AM <br /> 22 <br /> A� W ku,r o s. _4 0 a PM i� I _ ' � I lJ ® PM <br /> 0W ao �T <br /> - - - - -- - --- -- Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) (Fill one only) (Fill all that.apply) (Fill all that apply) (Fill all that apply) <br /> t Active Q Passenger Q Generator 0.Outdoor <br /> ' O Q Closed Q Altered <br /> GPS Latitude - i ! Q Hauler Q Indoor <br /> - -- - 71 -- -- ® 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 Q Agriculture Q Shredder Q Other I _ I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORC-MENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS 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 Date m / m 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 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 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 lfinlations <br /> Q 1 Q 1 Other: § <br /> Comments R � .{-;/_ ' '� u•S oVes I�Q �` a `WA-Is <br /> o r r"� <br /> Rb oSt-e Pi-e-S fi'om <br /> 1 e SerJ,Cg, OU6,0060J ow S ,i-e at ljI ls-U n leave i re ° <br /> w ���ed �'Iwr►�/� ��1�To rta�- ` a, �fi� e Tins c�`ol-, <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspect s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rrect• Incorrect: X A M1 P L E 111:2 3 <br /> White Co :CIW Yellow Copy.Operator Pink Copy:LEA <br />