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== Waste Tire Sui .ay & Inspection Report inspection Report Number <br /> LLS <br /> State of California <br /> CIWMB1811 teManag) Survey Form - Page 1 I 1 - 1143999 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � _ Q � Inspection Type (Fill one) <br /> ® � � � <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> LocalSa �� If Referral,choose referral type(Fill one) i <br /> Identifier: � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> AMt_rInspected By Inspector <br /> �i!,un�t l rc,G��n� �u(, <br /> Physical Address)r 3 1 — Q <br /> �e� Eszv�o <br /> ��� �� r���l Inspection Date <br /> P 7 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> % I p� V o 0 PM _1 5 ® PM <br /> --- - - — --- — - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 357 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Passenger 1@ Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) - - -- - ---j <br /> New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 [EN.F ORCEME.1 INT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 FP / M / T <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 I 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 <br /> i ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �1A1n[ �?.(� <br /> Inspection Form Included: Q _� j <br /> Comments Included: 01 `� ""v` Q/tl 0�'13 Q _ <br /> ---Bus! s p's Signature Phone Number Inspe is 'gnature Phone Number _1 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X A�, X A , _ 1 ` 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink py: <br />