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'- Waste Tire Sun vey & Inspection Report Inspection Report Number <br /> "'-Z- State of California <br /> Survey Form - Page 1 14 - 1 0 0 6 1 1 $ <br /> CIWMB 181(New 04104) <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 /> Site Suffix: L> Z �- - J Routine ®Re-inspection Q Referral Q Observation <br /> Local <br /> Identifier: li`h Cj I If Referral,choose referral type(Fill one) <br /> � �"`L c�'� u�.nti <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> CA^ .}. Inspected By Inspector <br /> Physical Address , -1 _ 1 0 l <br /> Inspection Date C <br /> Time In Time Out <br /> Business Rep Title _ O AM Q AM <br /> -L - Z O PM \ Z_ ' _ ® PM <br /> t Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude O Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 9P New Tire Dealer Q Auto Repair Q T,-eking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 6 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part 6 - <br /> V A Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _ HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Regstration and Transport of Tires Q Notice Of Violation Q Extension <br /> 5 <br /> PRC e 42953-Contracts with Re <br /> Q Q g s-ered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal ehicle <br /> Q O 14 CCR§ 18459 -Responsible Ent:es Complying with Manifesting Requirements Date m m / m <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Pegram ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Ma-fest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> i <br /> Q Q 14 CCR§ 18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> ---------------- ------------- <br /> 0 <br /> ----------Q Q 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® <br /> Q Q Other: § In Compliance - No Violations <br /> Comments <br /> (r'VVI` "�7 �'�V. C ✓� SCJ ,1 is tT ;�```'�'` of t, LV-1? C7Vl <br /> LAO <br /> Tl <br /> Inspection Form Included: Q <br /> Comments Included: <br /> siness p' Signature Phone Number In ector's Signature 9 Phone Number <br /> INSTRUCTIONS O BA K Correct: Incorrect: N/ ILE XIA MIP LIF 11 2J.311 62081 <br /> White C- . ..'.'3 Yellow Copy:Operator Pink Copy LEA <br />