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Waste Tire Survey & Inspection Report Inspection Report Number <br /> eee: <br /> Lim <br /> CIWMB181(New 04104)State California Survey <br /> Form - Page 1 Il - 1086925 <br /> California Integrated Waste Management Board <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i Inspection Type (Fill one) <br /> Site Suffix: 1Ell - [0] ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: 1r t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> nC <br /> L7�}���J_Y�l_SO_�h1 <br /> i <br /> Q01-11 s, ox-A r I <br /> Street 6 <br /> rI Inspection Date �� / mog <br /> Clry c�l Ly State ZIP Code Time In Time Out <br /> Business Rep 11111 Title m/ ' ®0 AM <br /> PM I� S i/ ' Q AM <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - i i Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer . Q Auto Repair ®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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of 1/iolation Q Extension <br /> 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 <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 ExTI <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!C-IWMB 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 /> Q Q Other. § <br /> CommentsYL'o _ � 6! — <br /> T <br /> 'y2 << <br /> Inspection Form Included: <br /> i <br /> Comments Included: T <br /> usiness R 's Signature Phone Number lns or' Sig ture Phone Number <br /> INSTRUCTIONS ON BACK E X AP E 1112 3 <br /> 62081 <br /> White C7CIWMmYellow Copy.Operator Pink Copy.LEA <br />