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r.� Waste Tire Su:,- Inspection Re ort'*ection Report. Number <br />p p <br />&fiEE" State B California fj a <br />E. CIWM8181tNew04104) Survey Form - Page 1 i 9- i U Z 8 4 <br />I California Integrated Waste Management Board 7 <br />9 <br />Survey <br />BLUE OR BLACK INK PEN <br />l <br />Part A - Su a li <br />W. <br />Business Profile Inspection Details <br />14PID -1 <br />( <br />Cal <br />Inspection Type (Fill one) <br />Site Suffix: <br />. <br />@ Routine Q Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />L c I <br />Identifier: <br />%; <br />j <br />06 C �,t h 1 0 fii tti .i <br />Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br />Business or Facility Name- <br />— W <br />Inspected By Inspector <br />Physical Address <br />Inspection Date <br />Street <br />Eli) Al— <br />'I ct!-pk 15 05 <br />Time In Time Out <br />0 AM AM <br />F m�m <br />City State ZIP Code <br />Business Rep Title <br />1, r: vlt ►.t Ct A ✓I w tl i/ I 0 Vj tv ✓ , <br />m0PM 0PM <br />- - _ <br />_ <br />Tire Count (Whole/PTE) J <br />Operational Status Tire Type Business Role Storage Type <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />Active Q Passenger 0 Generator 0 Outdoor <br />O Closed Altered <br />O <br />GPS Latitude <br />m <br />�= <br />O Hauler Indoor <br />0 Inactive 0 Truck <br />Longitude - <br />Q Planned OTR O End -Use 0 Container <br />kBusiness Type (Fill all that apply) <br />i 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader .0 Dismantler Q Tire Derived Fuel <br />_. <br />I'- <br />Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />-6 <br />Q Service Station 0 Hauler O Agriculture 0 Shredder 0 Other I I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />V; A ' HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br />Q O i PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />C4 ; O PRC § 42953 - Contracts with Registered Waste Tire Haulers. Compliance Deadline <br />I <br />0 O PRC § 42956 - Registration/Decal in Vehicle <br />0 O 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date <br />m <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0" O '14 CCR,§ 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or IDMti �'t " <br />0 O , 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O I Q ` 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers 0 Referred / CIWMB Enforcement <br />O Q 14 CCR § 18461 - Manifest System,&,%yirements for Waste Tire End -Use Facilities - _ ----___ <br />O 0 14 CCR § 18462 - Manifest System Requirementslol~Tire Dealers or Waste Tire Generators @ In Compliance - No Violations <br />�'O- <br />[ Other: § <br />,Comments !�t^l(JC{ ;� �. <br />C( (J (./,�� �r�[CtC' (- as jr. �l �U ✓'r It�il /P�e� <br />vv D 100 —';?00. � � c� � r r l r � _ a �1 t' S <br />G l/ffJ. Mitt ;t�H Airc(rl.�c�(11 IMc(t�I.�.�t''.i 1 e►i `-+fC dr �clr <br />on Form Included: 0. <br />. r ' <br />nspe:MFRQnts <br />Included: 0Business <br />Phone Number Inspector's p� g Signature Phone Number <br />Rep's Signature <br />INSTRUCTIONS ON BACK Correct:4 Incorrect: �/ A:.A�dh .l 2 �2osa, <br />-�� n - <br />'� White Copy: CIWMB e I w Copy: Operator. Pini=Copy,LEA:"' <br />