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FORM NO.M-105547-CIWMB M12 d B e 7 6 5 4 3 2 1 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 1 0 7 9 4 9 4 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' 3 S 0 I ! Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��qy� Cwt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date ( 2 CD <br /> �rw�kco.. � Ct�3V 'T <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> (� S{-D YZ- ® PM PM <br /> ©i ftp Iry CtNlO <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IIs Active ® Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 ENFORCEMENT STATUS <br /> V r A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No..yi .I ti t► <br /> Q 1 Q Other: § <br /> Comments <br /> r.j %+��_—�c�se�k�t�- cx� !!70k�s e(r�.���Z�srs—�re.lrs�� T`►•� <br /> QTS VW.AA 6te-nq . AA Mas LE p4L 2= 1 wLCnA ZHI s- <br /> Inspection Form Included: Q w• �q� �s_U �� <br /> Comments Included: Q I 7 <br /> Business ep s Signa ure Phone Number Inspector's Signature Phone Number <br /> 89081 <br />