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Waste Tire SurZTe & Inspection Re o"inspection Report Number <br />State Y p p <br />CIWMB <br />f 81 (New <br />Survey Form - Page 1 I 1- 1.140753 <br />CIWMB 181 (New 1nage) <br />California Integrated Waste Management Board <br />Part A --_Survey-_- — _ _ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID a _ 1 Inspection Type (Fill one) <br />Site Suffix: V t� J , ® Routine 0 Re -inspection 0 Referral 0 Observation <br />LocalQp�'�� If Referral, choose referral type (Fill one) <br />Identifier: S�11� J 01tjt -11Tfl �-lJ� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />Camino Ttes <br />Physical Address <br />Sko &k0 CA `1SM5 <br />Business Rep Title <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />O <br />Longitude — <br />Business Type (Fill all that apply) <br />Inspection Date <br />Time In <br />1 b <br />' <br />C5 0 AM <br />I � <br />0 PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill all that apply) <br />10 Active <br />10 Passenger <br />0 Closed <br />0 Altered <br />0 Inactive <br />0 Truck <br />0 Planned 0 OTR <br />* New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 114 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 114 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 Other: § <br />Comments � � L I <br />o 9 <br />1 b <br />Time Out <br />I � <br />O Q AM <br />46 PM <br />Business Role <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />• Generator <br />• Outdoor <br />40 Hauler <br />0 Indoor <br />0 End -Use <br />0 Container <br />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date Mi <br />/ / M11 <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 in Compliance - No Violations <br />I <br />Inspection Form Included: 0 <br />Comments Included:*' <br />11-7 9 <br />Business Reps gnatu Phone Number Inspect ignature Phone Number <br />INSTRUCTIONS ON BACK Correct 40 Incorrect 081 <br />,� V E l� 1 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Co : A © ■ <br />