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Waste Tire Surv.,:y & Inspection Report tpectionReport Number <br />State of BCalifornia /I (� <br />California <br />CIWMB 181 (New nage)Survey Form - Page 1 4 VX <br />California Integrated Waste Management Board <br />'art A- Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - 4 4 _ Inspection Type (Fill one) <br />Site Suffix: 18 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: CL%LAY Vr\ - — 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name () Inspected By <br />PC, ;� —� f -<L 5ko P 3 <br />Physical Address - ) <br />has N <br />Lock; <br />Business Rep <br />Tire Count (Whole/PTE) <br />Longitude - <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />CA <br />Title <br />0 1 <br />Inspector <br />Inspection Date U / © <br />gs2yo <br />Time In Time Out <br />ow ✓ c -v - <br />0 S <br />O AM <br />0 ®PM <br />0 Z 2� <br />O AM <br />•PM <br />Operational Status <br />O <br />Business Role <br />Storage Type <br />O <br />0 S <br />O AM <br />0 ®PM <br />0 Z 2� <br />O AM <br />•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 />40 Active <br />0 Passenger <br />* Generator <br />® Outdoor <br />0 Closed <br />0 Altered <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />0 Hauler -(D <br />indoor-- — <br />0 inactive <br />0 Truck <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Trucking Fleet 0 Government 0 Retreader <br />• 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 />............ -- ---......-. _ - -- <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 : 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 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 />0 <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 />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date m / El <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />® in Compliance - No Violations <br />Comments <br />— OLL- a YLe, 1 In C 'rAri csyv vY� +-L. i C_ GJ(CA - <br />':Inspection Form Included: 0 <br />Comments Included: ® uIv -- -� <br />Business Rep's Signature ne Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X ;�, \J'E` M, 12 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Cop . LE L=► <br />