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ELM Waste -Tires! M& Inspection Rportspectign Report Number <br />688`- State of California "- ! � <br />986P6 CIWMB 181 (New 04/04) Survey Form - Page! I- ;� 0 1 5 1 1 <br />1 California Integrated Waste Management Board <br />Part A- Survey BLUEDR BLACK INKTEN <br />Busine s Profile ; Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: . <br />E2— Q Routine Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier:, Q CHP. Q CIWMB Q Complaint Q Educational Visit Q Other <br />B F 'I't N <br />usmess or ac l I y ame <br />V <br />Inspected By <br />HAULING AND MANIFEST REQUIREMENTS <br />Inspector <br />Q <br />PRC § 42951 -.Waste Tire Hauler Registration and Transport of Tires <br />Q <br />3 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />/ j <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Physical Address. <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR-§ 18459.1 - Tire. Program ID Number from CIW.MB <br />Q <br />Q <br />r <br />Q <br />Q <br />I. 64li <br />Q <br />Inspection Date } <br />7 <br />J <br />Street <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />(� <br />n, <br />Other: § <br />City <br />Business Rep <br />State ZIP Code <br />Title <br />Time In <br />0 AM <br />Time Out <br />Q AM <br />EE <br />5 PM <br />1= 0 PM <br />1. I I <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all,_that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (Whole/PTE) <br />, <br />Q Active <br />Passenger <br />'Generator <br />(0,'Generator <br />Outdoor <br />Q 'Closed . <br />Q Altered <br />GPS Latitude <br />m <br />• <br />IT]o <br />Q Hauler. <br />Q Indoor <br />0 <br />Q Inactive <br />Q Truck <br />Longitude –F-17-1.1 <br />I <br />t 1 <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q1Container <br />................. - ....._ .._ .. -. <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair . Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />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 - Tire. Program ID Number from CIW.MB <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 />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />(� <br />n, <br />Other: § <br />ENFORCEMENT STATUS _ <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date/m�m <br />f (Required for NOV or EXT) <br />Q Referred I CIWMB Enforcement <br />Q In Compliance - No Violations <br />Comments <br />7_ -j <br />Inspection Form Included: Q <br />Comments Included: Q', - - <br />Business Rep's Signature Phone'h <br />INSTRUCTIONS ON BACK' Correct:* Incorrect:,X j <br />■ White Copy: CIWMB Yellow Cop Op <br />4 <br />imber•'' Inspector's Signature_ <br />-1,112 <br />rator Pink Copy: LEA <br />Phone Number <br />62081 <br />i <br />