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Waste Tire Su. :y & Inspection Report Inspection Report Number <br />-= State B CaliforniaClWM! 7 7 2 - 1 0 1 0 5 <br />California Integrated ,Was81 tJe Manageew 04/0` ment Board Survey Form - Page 1 r { <br />Part A -Survey BLUE OR <br />BLACKI <br />PEN <br />Business Profile Inspection Details i <br />TPID - ( L � - F 7, ili Inspection Type (Fill one) <br />Site Suffix: �! �( 1 Routine Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier: <br />Business or Facility Name <br />I <br />Physical Address <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 />%1 f �.,�: ✓� l._ I1�'( <br />Street t / <br />t (� n � l -. --, � � Inspection Date <br />EE <br />/ I <br />�� <br />State _ Code � Time In Time Out <br />Ciro Z1P _ _ <br />Business Rep Title L <br />O PM �O AM <br />� � 0 P <br />I Operational Status Tire Type Business Role Storage Type <br />Tire Count Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />0 Active 0 Passeng 0 Generator 0 Outdoor <br />O (0 Closed 0 Altered <br />Latitude i j I. <br />GPS W 0 Hauler Indoor <br />0 0 Inactive ,0 Truc <br />Longitude - 0 Planned 0 OTR 0 End Use ontainer <br />0 New Tire Dealer <br />0 Auto Repair <br />0 Trucking Fleet <br />0 Government <br />0 Retreader <br />0 Used Tire Dealer <br />0 Auto Body <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 Service Station <br />0 Hauler <br />0 Agriculture <br />0 Shredder <br />0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />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 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire 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 />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred I CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments c r C� (`.� -t%(�ri ti�i 1 ' <br />►' t 1� U ( Y � 1 o t ''`JCS `- {,✓1 cj d I t�� �% � O ['1 6 <br />( c) J; le 0cit Ur ErlF ►�C4iri <br />Inspection Form Included: 0 <br />Comments Includedusiness <br />Rep's Signature <br />Phone Number <br />In*Rector's Sig atur <br />Phone.Nu. <br />INSTRUCTIONS ON BACK Correct:* <br />Incorrect: X <br />3(, ?,�, p <br />62081 <br />White Copy: CIWMB <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />® <br />t <br />