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im <br /> Waste Tire Suay & Inspection Report Inspection Report Number <br /> Slate B California Il - 1140643 <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: 3 la - d 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �,.. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - — --- <br /> Business or Facility Name <br /> Inspected B <br /> P Y Inspector <br /> cCvv / <br /> jPhysical ddress 3 y - ` Q <br /> 2x/00 -- <br /> Inspection Date I C) <br /> L tttr�p CA �5330 T <br /> Time In Time Out <br /> Business Rep y Title 0 AM 0 AM <br /> � X.vV1�Gt <br /> t ,5 � �yNe�u f vZ PM d 3 d ® PM <br /> - - Operational StatusTire Type Business Role I Storage Type <br /> Tire Count (Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �p ®Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> l <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 1 A HAULING AND MANIFEST REQUIREMENTS 0A44"", Q Notice Of Violation Q Extension R <br /> Q Q 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 1 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 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/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 • In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> - <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Busi p Sign Phone Number Inspector's Signature t Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i� XIA,i �KLjt�l 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />