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Waste Tire Sup vey & Inspection Repoi. _ Inspection Report Number ■ <br />;111 State B CaliforniaCIWI 1 - 1127914 <br />California lnteg ttdWaste Management Board Survey Form - Page 1 <br />Part A- Survey - _- - -_-_ BLUE OR BLACK_ INK PEN_ <br />Business Profile Inspection Details <br />TPID -Inspection Q I Inspection Type (Fill one) <br />Site Suffix: , 0 Routine 40 Re -inspection 0 Referral 0 Observation <br />Local �� / If Referral, choose referral type (Fill one) <br />Identifier: (��(1 J ��n 1,1 J 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business ol�Facility Name �j Inspected By Inspector <br />(afn'n-o 1 1I tees _ <br />Physical Address 3 <br />3M <br />Inspection Date ) <br />�nt'v�nr\ cA gs�s `� 1 <br />Time In Time Out <br />Business Rep TitleO AM O AM <br />I O O r PM PM <br />ame- <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />Operational Status Tire Type <br />(Fill one only) (Fill all that apply) <br />40 Active 40 Passenger <br />0 Q Closed Q Altered <br />O Q Inactive Q Truck <br />Q Planned Q OTR <br />® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q <br />Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br />Q <br />Service <br />Station 4 Hauler Q Agriculture Q Shredder Q Other <br />Part B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />j HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <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 />O <br />_0 <br />14 CCR § 184592.1 — Submittal of Comprehensive Trip -Logs within 90 days _- <br />Q <br />O <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 />0 <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />O <br />Other: § <br />Comments I I - <br />C9 outs In-% a t,n ae 0f,\ 1 *11 l b . - i n SQC J1 I <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator e Outdoor <br />It Hauler <br />Q End -Use <br />Q Indoor <br />Q Container <br />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date /m/m <br />(Required for NOV or EXT) <br />Q Referred /CIWMB Enforcement <br />® In Compliance - No Violations <br />I] <br />Inspection Form Included:11 <br />p of _ Z`� '70 <br />Comments 4-317d <br />Comments Included: Q, - <br />u ess Rep's Signat re Phone Number Inspec 's Signature hone Number. <br />INSTRUCTIONS ON BACK Correct.* Incorrect: � � �{ h Z 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Cop ■ <br />Int 11 �iSG1�1�7L15 <br />� 1��(JUL1[�f1S I 1/A\12. <br />I1�Q.�1 <br />L�S�Q,�- cU` . <br />Inspection Form Included:11 <br />p of _ Z`� '70 <br />Comments 4-317d <br />Comments Included: Q, - <br />u ess Rep's Signat re Phone Number Inspec 's Signature hone Number. <br />INSTRUCTIONS ON BACK Correct.* Incorrect: � � �{ h Z 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Cop ■ <br />