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■ r`e9a Waste Tire ey & Inspection Rep Inspection Report Number <br />ara State CIWMB cauror w - 112 7 6 9 4 <br />grated Waste <br />Survey Form - Page 1 <br />California Integrated Waste Management Board BLUE OR BLACK INK PEN <br />art A - Survey <br />Business Profile Inspection Details <br />TPID -i � � � � Vp � m ® � Inspection Type (Fill one) <br />Site Suffix: 4 .0 Routine o Re -inspection o Referral Q Observation <br />Local c �I <br />Identifier: J ate V�B <br />Business or Facility Name <br />n M �6� <br />Physical Address <br />C.nun�,� <br />sir \ ti c e_� G - ACS <br />3SY mvc L Ave- <br />4h <br />ve- <br />4 oh &k0 r\ CA 15,101 <br />Business Rep `_ Title <br />Tim �ac�-tS S�4.wIsor <br />Tire Count (Whole/PTE) 9 <br />s � <br />O <br />GPS Latitude <br />O <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Trucking Fleet <br />Q Used Tire Dealer O Auto Body Q Car Dealer <br />Q Service Station Q Hauler O Agriculture <br />If Referral, choose referral type (Fill one) <br />Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />_� � 1 D I Rcn EscA o <br />Inspection Date a o / 1 0 <br />Time In Time Out <br />L� SAMl OAM <br />' l ePM O� ®PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />Q Passenger <br />IS Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />o <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />o Hauler <br />®Indoor <br />O Inactive <br />® Truck <br />o <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />o Planned <br />® OTR <br />o End -Use <br />o Container <br />Q Government <br />Q Collection <br />Q Shredder <br />Retreader <br />O Crumb Rubber <br />• Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />T A <br />HAULING AND MANIFEST REQUIREMENTS <br />O <br />o <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />o <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />o <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />o <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />o <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />o <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 />Q <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />o <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Other: § <br />Comments ` ��i(1S�cS iOn (kAblmt',J' <br />V iOvc.'. I. f (U:1 <br />Dismantler O Tire Derived Fuel <br />ENFORCEMENT STATUS <br />o Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />O Referred / CIWMB Enforcement <br />• in Compliance - No Violations <br />nspection Form Included: Q + <br />Comments Included: -u — — �' nP. <br />_ Ain ep s tgnature Phone auer� Inspe_ is Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: I* Incorrect: X I �C , M 3 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Co y: L ® ■ <br />