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■ caY Waste Tire Su -y & Inspection Report Inspection Report Number ■ <br />If[ State B CaliforniaC,WM04104) <br />Il - 1140665 <br />California Int gr edf81 Was eeManagement Board Survey Form - Page 1 <br />Part -A-- Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection © 4 ( Inspection Type (Fill one) <br />Site Suffix: T ® Routine 0 Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier: �L �4 Co <br />Business or Facility Name <br />r -9—Q - <br />Physical Address 'l <br />6 S soc) M <%VAlf_'j <br />Lm*t f- O r <br />Business Rep <br />Tohuj &Jil-k- <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />P'Ca' <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />if_IA 95334 <br />Inspection Date <br />o 9 <br />' -71 <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Time In <br />0 <br />Time Out <br />0 <br />TitleIT <br />/ : O <br />S <br />o ® PM <br />G ' <br />0 AM <br />0 <br />0 <br />1 <br />l <br />e PM <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Operational Status I <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that api: <br />(Fill all that apply) <br />(Fill all that apply)! <br />0 Active <br />0 Passenger <br />® Generator <br />0 Outdoor <br />O <br />0 Closed <br />0 Altered <br />WA <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />®Truck <br />O <br />li <br />Longitude — Planned 0 OTR 0 End -Use 0 Container <br />Business Type (Fill all that apply) <br />0 -New Tire Dealer 0 Auto Repair a Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A ! HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 -Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0i <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred/ CIWMB Enforcement <br />in Compliance - No Violations <br />_:- <br />Commentstr <br />1 <br />��-- <br />Inspection Form Included: O <br />Comments Included: t�l <br />Busine/s�7ftp'signature Phone Number <br />INSTRUCTIONS ON BACK: Incorrect:,. <br />White Copy: CIWMB Yellow Copy: Operator <br />Pink <br />62081 <br />