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Waste Tire Sui y & Inspection Report-, nspection Report Number <br />i, State B California I- 1127870 <br />Cgrated Waste <br />eManag) Survey Form - Page 1 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - f q - O r Inspection Type (Fill one) <br />Site Suffix: 1 ® Routine Q Reins ection Q Referral Q Observation <br />Local <br />Identifier. S-o,Y-N --b��� <br />Business or Facility Name J <br />AF A <br />Physical Address <br />U 3 Sur'/�"v sc, Kcl. <br />p I <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />® Active Q Passenger t® Generator Q Outdoor <br />0 Q Closed Q Altered <br />Q Hauler Q Indoor <br />D Q Inactive 0 Truck I i <br />Q Planned Q OTR Q End -Use ® Container <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Collection Q Crumb Rubber <br />Q Shredder ® Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 1 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 <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 <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 <br />Q Q ( Other: § <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 />® In Compliance - No Violations <br />Comments <br />---ozcfin.e—;�ac,�cc�r�w _ 7i�� av��l <br />�v ll� jitcc f�vfcel <br />ction Form Included: d <br />Comments Included: ®i -- -- -- -''�/ <br />Business Ffep's Signature <br />INSTRUCTIONS ON BACK LCorrect: <br />White Copy: CIWMB <br />�106_N-0 - - - -- --1 41 W-1 0(- z <br />Phone Number nspecto SiSignature Phone Number <br />Incorrect: X %i V i j 12 i i i 62081 <br />Yellow Copy: Operator Pink Cop : 1 — i <br />Inspection Date <br />` / <br />X0 % <br />cA 9s-wg- <br />Time In <br />Time Out <br />Business Rep <br />Title© <br />a <br />® AM <br />` ®AM <br />0 PM <br />0 PM <br />i - <br />Operational Status <br />Tire Type <br />Business Role Storage Type <br />Tire Count (Whole/PTE) <br />( <br />Fill one only)Fill <br />( all that apply) <br />(Fill all that apply) (Fill all that apply) <br />' <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />® Active Q Passenger t® Generator Q Outdoor <br />0 Q Closed Q Altered <br />Q Hauler Q Indoor <br />D Q Inactive 0 Truck I i <br />Q Planned Q OTR Q End -Use ® Container <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Collection Q Crumb Rubber <br />Q Shredder ® Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 1 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 <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 <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 <br />Q Q ( Other: § <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 />® In Compliance - No Violations <br />Comments <br />---ozcfin.e—;�ac,�cc�r�w _ 7i�� av��l <br />�v ll� jitcc f�vfcel <br />ction Form Included: d <br />Comments Included: ®i -- -- -- -''�/ <br />Business Ffep's Signature <br />INSTRUCTIONS ON BACK LCorrect: <br />White Copy: CIWMB <br />�106_N-0 - - - -- --1 41 W-1 0(- z <br />Phone Number nspecto SiSignature Phone Number <br />Incorrect: X %i V i j 12 i i i 62081 <br />Yellow Copy: Operator Pink Cop : 1 — i <br />