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=E Waste Tire <br />Sy &Inspection Repo <br />nspection Report Number ■ <br />CIWMB181'(Nwka 04%04) <br />Board <br />Survey Form <br />-. Page1 <br />1 2 - -�10 �10 <br />5 9 3 <br />California Integrated Waste Management <br />Part A - Survey <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Site Suffix:i <br />� <br />- <br />��� <br />I I <br />I <br />Inspection Type (Fill one) <br />(-)ine <br />R tQ Re -ins ­fl­­fl­Q Referral Q Observation <br />Local <br />Identifier: l `t 1!1 <br />Business or Facility Name <br />FliczH If <br />-7o r( G(t 'i Ce' G4 <br />r-0 6i 1 7 0 6 J irk <br />ou y p <br />If Referral, choose referral type (Fill one) <br />O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br />Inspected By Inspector <br />F, Fo h I i Jo,iii (-Y-o <br />Street p <br />Inspection Date <br />JA <br />City State ZIP Code Time In Time Out <br />Business Rep ( Title O AM O AM <br />MOPM m O PM <br />I ��-�"�jt_•'�t !J, t'' f' . l's,. ! f .�I \it'f.if1� f� I --- —' - <br />Operational Status Tire TypeBusiness Role Storage Type <br />Tire Count Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />[I,=,= <br />Q Active Passenger 1 Q Generator 0 Outdoor <br />GPS Latitude <br />O (0 Closed 0 Altered <br />m , <br />O Q Inactive , Truck <br />Longitude - O Planned 0 OTR <br />Business Type (Fill all that apply) <br />Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government. Q Retreader <br />Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection O Crumb Rubber <br />0 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 A HAULING AND MANIFEST REQUIREMENTS <br />0 Q PRC § 42951 - Waste Tire Hauler Registration and Transport of,,Tires <br />O 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 Q PRC § 42956 - Registration/Decal in Vehicle <br />O 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 .14 CCR § 18459.1 (a) (b) (c) -Tire Program ID Number from CIWMB <br />Q 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q Q 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 Q 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q 0 14 CCR § 18461 - Manifest System Requirements for Waste .Tire End -Use Facilities <br />0 Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q Q Other: § j �_ dosed <br />L �f <br />Comments l (} X11' C} hoc) f )F fi t { � ose d int.( oa..V'"cl l or . Vl eF <br />s,i-o(ed eta. IW --j `( � Gc1(1I 1.)c Jit1�'IuC�eC� c�J <br />—01 <br />< I/ I <br />Q Hauler <br />Q End -Use <br />0 Indoor <br />0 Container <br />Dismantler O Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q In Compliance - No Violations <br />rrcc <br />I <br />r <br />nspection Form Included:); <br />Comments Included @- --- - -.. - .. 4/. ... <br />Business Re 's Signature Phone Number Inspector's Signature Phone Number <br />,�7�4 <br />j—•' r <br />INSTRUCTIONS ON BACK Correct: Incorrect: ) �I1.rll, 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />