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Waste Tire Su & Inspection Reportspection Report Number <br />BEEE' Stateof California ■ <br />inCIWMB 181 (New nage)Survey Form'- Page 1 r I � - -1.0 3 �3�2 7��-8. <br />Californiaia Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: U -32 D( Routine <br />Q Re -inspection p Q Referral Q Observation <br />Local If. Referral, choose referral type (Fill one) <br />Identifier: �` -�"" <br />tJR 5- j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name /- - - — <br />J Inspected By Inspector <br />Physical Address/ <br />I a- <br />StreLst <br />� y Inspection Date / <br />City State Zlp Code Time In Time Out <br />Business Rep Title m m O0 AM 0 AM <br />PM m' m O PM <br />s <br />Operational Status Tire Type Business RoleStorage Type <br />Tire Count (Whole/PTE) ❑ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />6 Active (g Passenger Generator Outdoor <br />GPS Latitude <br />T710 <br />Q Closed Q Altered <br />m - <br />O Q Inactive Q Truck <br />Longitude - Q Planned Q OTR <br />L Business Type (Fill all that apply) <br />(a New <br />Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <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 <br />V <br />A <br />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 />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 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire 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 />Q <br />Q <br />Other: § <br />Q Hauler 10 Indoor <br />Q End -Use 0 Container <br />Dismantler Q Tire Derived Fuel I `, <br />ENFORCEMENT STATUS <br />(Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date M(- / 1�1 / —t <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q In Compliance - No Violations <br />Comments !� : __ f� r"t C� lJ '�� n✓�� r 5 �._ ` J7� ' ate.-.'�� r.• <br />^""'--( u(� _ ' r i � � ' .1 G )t-{? � �✓/�7 moi. ��i- f : �. � r+ . r �r'.... � . � ^ <br />,� � ' J. <br />- �,,���_ E',� �"ti � ;� ; � G. � � �.. J� 7 �'". i` � l.% } t • I^.../ -'T e .� /��r,. � ; '(`i.=• �7 I /'ice .�l <br />Inspection Form Included Qr _ <br />Comments includedI..-. .." -.- _ �..._.. - - - -fr L..... <br />Business Rep's Signature Phone Number InspectoF's Signature Phone Number <br />zj�INSTRUCTIONS ON BACK Correct:0 Incorrect: EJ .Alm p ,L 1 3 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator' Pink Copy: LEA ® S <br />