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Waste Tire Su, vey & Inspection Repor , Inspection Report Number ■ <br />State of 81 (New <br />Survey Form - Page 1 Il - 1143536 <br />CIWMB 181 (New nage Y <br />California Integrated Waste Management Board <br />'art A - Survey _ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - '�j Q h j Inspection Type (Fill one) <br />Site Suffix: 1 5 3 ( l� U 1 ® Routine Q Re -inspection Q Referral Q Observation <br />Local < If Referral, choose referral type (Fill one) <br />Identifier: U,1r) `^ �0�, ix n �ju� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />I_0,t�f s M as,ne, 9 _ ' j <br />Physical Address D I ,-)en <br />'A1) (� kXLkf_1 Cwt_ W u,y <br />Sfbc,\-LvOn cA 't5 <br />3usinnesstR�ep Title L <br />�) Onn, iJA <br />Tire Count (Whole/PTE) <br />� f <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />Q <br />Inspection Date <br />_? <br />0 lP <br />l U <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />11 <br />I HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />Time In <br />Q <br />Time Out <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />0 <br />I ` 0 AM <br />ck <br />Q AM <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />C� V <br />PM <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />PM <br />o <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />--- <br />o <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) (Fill all that apply) <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q Active <br />Q Passenger <br />Q Generator <br />Q Outdoor <br />O <br />Closed <br />Q Altered <br />%JIA <br />N/A <br />I' <br />Truck 'A <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q <br />O <br />OTR <br />o End -Use <br />Q Container <br />Q Planned <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Used <br />Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service <br />Station Q Hauler Q Agriculture Q Shredder Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />I HAULING AND MANIFEST REQUIREMENTS <br />Q <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 />o <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />o <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 />o <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 />o <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />o. <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />o <br />1 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments q MCA (X) <br />OJ <br />Q Dismantler Q Tire Derived Fuel <br />rnkn nil, <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m Fr] <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />ns ection Form Included: " <br />Comments Included: I*1 <br />Busin s Rep's Sig ature Phone Number Insp tor's Signature �J Phone Number <br />I <br />- - - <br />INSTRUCTIONS ON BACK Correct.+♦ Incorrect:N i E A P ` (� I 62081 <br />■ <br />-- - - ■ <br />White Copy: CIWMB Yellow Copy: Operator Pink Co : L A <br />