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4 <br />Waste Tire S & Inspection Repo4espection Report Number ■ <br />642 State <br />CIWMBf California Il -1088276 <br />California InegratediWase81 eManagement Board Survey Form -Page 1 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile - --- <br />Site Suffix: I 1- Q 15 3 I 1 _ - 0 <br />L <br />Local <br />Identifier: �5 GY1 -1 OQOU i rl ��Ur1T <br />BF ilit Name <br />1. Inspection Details <br />Inspection Type (Fill one) <br />Q Routine Q Re -inspection 'i Q Referral � Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />usmess or ac y ._ <br />Inspected By <br />PRC § 42951 -Waste Tire Hauler Registration and Transport of Tires <br />Inspector <br />Physical Addr s� <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />-5 <br />1 <br />- <br />m- <br />Q <br />0PM <br />KrIttInh_ L.0 C'I$ <br />) <br />I <br />Operational Status Tire Type <br />;er <br />Inspection Date � � 1 � FOIL/ <br />LocyA.rd CA, q52_37 <br />State ZIP Cu, Time In Time Out <br />Business Rep Title <br />Tire Count(Whole/PTE) o <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />[Q <br />0 <br />0 AM <br />PRC § 42951 -Waste Tire Hauler Registration and Transport of Tires <br />Q <br />0 AM <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />�• <br />0 P <br />m- <br />Q <br />0PM <br />M,nf <br />) <br />I <br />Operational Status Tire Type <br />Business Role <br />Storage Type <br />,. (Fill one only) (Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Active Q Passenger <br />® Generator <br />Q Outdoor <br />O Q Closed Q Altered <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q Inactive QTruck <br />Q Hauler <br />Q Indoor , <br />p,// p <br />O <br />Q Planned Q OTR <br />Q End -Use <br />Q Container <br />Q Government Q Retreader Q Dismantler <br />Q Tire <br />Derived Fuel <br />Q Collection Q Crumb Rubber <br />Q Shredder ® Other M CtytU �ct ct ure r <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />[Q <br />0 <br />Q <br />PRC § 42951 -Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Other: § <br />FENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m , m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />Comments ( <br />�te.�'• t��-�Ye��_recl_�r�-�r1'� fcLc It Lczs�y_o�u��nerol-or <br />ctre ser Iae e Schb Ttre Cen} <br />1 t <br />—crr1 irf.:��w '_t. _r'�_T rl �� pr`T. A�� ,fi r• Ve�i1��2�_ <br />Inspection Form Included: Q , <br />Comments Included: Q - <br />Business Rep's Signature <br />INSTRUCTIONS ON BACK Correct:* <br />EWhite Copy: CIWMB <br />_ Phone Number _ In or's Signature _ _ Phone Number <br />62081 <br />Incorrect: X Ai L x AA P L El 112 3 <br />Yellow Copy: Operator Pink Copy: LEA ■ <br />