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ELIE <br /> Waste Tire Sur ,y & Inspection Report lspection Report Number <br /> _ State of California <br /> CIWMB 181( eSurvey Form - Page 1 I 1 - 1140806 <br /> California Integrated Waste Management Board <br /> Part A-Survey__ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / D 1 3 - © f Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: tl�' Curaf Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name—/ Inspected By Inspector <br /> Physical AdcTress ' d /7N16y1/LG�t <br /> YGO F <br /> �} <br /> Inspection Date Z Z f <br /> L Cs �• C/�- �j 5 Z.V0 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> i ;z, • 0 0 ® PM V t/ ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ILI .- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 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 /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i 0 Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments Inspection Form Included: 0 <br /> Comments Included: <br /> BushAss Rep Signature Phone Number/ nspectoes Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X /v \/ C XI A, MI P I L I E1 I g 1 2(31 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />