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Waste Tire Su► ;y & Inspection Report inspection Report Number <br /> State of California 11 - 1140959 <br /> California Ine Brat d Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survr y BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i <br /> TPID- / g i S Inspection Type (Fill one) <br /> a <br /> Site Suffix: ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: �C(, l `� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '�T �'' Inspected By Inspector <br /> C-V �� S/V <br /> PhysicalL J /dress g — / 0 / <br /> d Lam`n G 0//-L, , <br /> Inspection Date 0 / ! 3 / U <br /> Time In Time Out <br /> Business Rep Title /� ® AM _ ® AM <br /> Ac 4i Vl� c}���►' / / Q ® PM 1 S PM <br /> L�rr7;e, De-16-Cry Z M if(Ak V'U'C. - -- - -- <br /> — - 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 0 Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 ! Q Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 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 /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 ! 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> 00 Other: § <br /> Comments n <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector' Signa u Phone Number <br /> -- -- - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X XI A � 62081 <br /> White Copy.CIWMB Yellow Copy.Operator Pink op A <br />