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Waste Tire SL ey & Inspection Repor, Inspection Report Number ■ <br />State of California <br />CIWMB181 <br />I 1- 1127947 <br />California Integrated Was eeManagement Board Survey Form - Page 1 <br />Part A- Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection Type (Fill one) <br />Site Suffix: ?j -r Inspection <br />© 1 ®Routine Q Re -inspection Q Referral Q Observation <br />LocalC�,�� If Referral, choose referral type (Fill one) <br />Identifier: �7( i��y Cy1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By <br />Ste: Av% 3 9 l c� <br />Physical Address <br />S . 'Et <br />`v`' iTj� ' r✓ . 1 <br />Business Rep <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />CA 450 C6- <br />Title <br />Inspection Date <br />Time In <br />II 11 <br />t l <br />Operational Status <br />(Fill one only) <br />40 Active <br />Q Closed <br />Q Inactive <br />Inspector <br />G( / ( 1 <br />Time Out <br />® AMi <br />Q AM <br />0 P <br />L� 0 P <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Passenger <br />® Generator <br />Q Outdoor <br />Q Altered <br />Q Hauler <br />1 ® Indoor <br />Q Truck <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Longitude — -LOPlanned Q OTR <br />Business Type (Fill all that apply) <br />0 End -Use Q Container <br />Q <br />New <br />Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />40 Dismantler Q Tire Derived Fuel <br />Q <br />Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q <br />Service <br />Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS __ <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />M/m/m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXE <br />Q <br />Q-- <br />14 CCR § 18459.3 -Retention of Comprehensive Trip Logs for 3 years <br />---- <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CIWMB Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />L <br />Comments <br />inspection Form Included: Q <br />Comments Included: — --- -- ---- <br />Business Rep's Signature Phone Number I ct 's Sin ure — _ Phone Number <br />INSTRUCTIONS ON BACK �Correct:0 Incorrect '^ -fes V f� ,� , 4 i a� 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Co' : L ®. . <br />