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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California I 1 1143592 <br /> CIWMB181 <br /> Waste <br /> eManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- I l Inspection Type (Fill one) <br /> Site Suffix: lQ 3 (� g 1 0 1 O Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: SC.�� d"IA11) J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> (14� <br /> ( nn Land c,,na C_ a - 1 0 a <br /> Physical Address 3 I 1�e._n <br /> - - <br /> ��� <br /> Inspection Date � � 0 <br /> Yr,,.rm,n �an � � <br /> Uri <br /> Time In Time Out <br /> Business Rep / Title 1 O 0 AM PM I # PM <br /> 1 A�I D l� f G1I G, u�('hcr' -- - ---- <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 /> 3 0 S Active Passenger ® Generator Is Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive �Truck <br /> Longitude - End-Use Q Container <br /> O Planned OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder . Other Fa irn <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - _ - <br /> V �, A ;HAULING AND MANIFEST REQUIREMENTS§ � <br /> O O PRC 42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 Q Other:: § <br /> Comments <br /> �.L <br /> I I <br /> -iv -v ,o_laka vn s 0 s u ctac, <br /> Inspection Form Included: Qi, r �( <br /> Comments Included: 11111 !+��"2SNumber <br /> (L!O � ,317$[[[��is„iness Re 's Signature Inspe r s ',nature hone Number, <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect y V fm tai P f131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />