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fi <br />0832SOS0013 ■ <br />CIWMB <br />== : Waste Tire Survey & Inspection Report Inspection Report Number <br />State Of 181 (New California 04/04) �/ Surve Form - Page 1 I1 - 1088405 <br />California Integrated Waste Management Board <br />Part A - Surva_v RI tJF r)R RI ACK INK PFN <br />Business Profile <br />Inspection Details <br />A <br />I HAULING AND MANIFEST REQUIREMENTS <br />TPID - i .- I <br />Site Suffix: <br />Inspection Type (Fill one) <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />Q Routine Q Re -inspection Q Referral Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: <br />an 70aq lain Goun-'y I <br />Business or Facility Name <br />Inspected By Inspector <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />UEac _C�x_a►ns_% Sara Let <br />�� _ ' <br />o <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Physical Address <br />1c,1 I <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Street <br />Inspection Date F <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 15 <br />�- <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />_— <br />----- <br />C'iy Cod'' <br />Tim_ a In- <br />Time Out <br />— - - <br />Business Rep Title <br />( ©' : I 0 AM <br />0PM <br />AM <br />I I '12O'OPM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />f <br />9 Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />Q Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />O <br />Q Inactive <br />0 Truck <br />�Ih <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Cl Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />I HAULING AND MANIFEST REQUIREMENTS <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 />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <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 />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <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 />In <br />17 <br />Other: §. <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem / m / m <br />(Required for NOV or EXT) <br />Q Referred f CIWMB Enforcement <br />40 In Compliance - No Violations <br />Comments =Yll"14,—�Os_c�_a�erarrn�� 0 1lQ'Alr9 w_Q5 <br />'tt�'e.� o N_ _o--It�es s�-o��or.-srte..�Faci 1�i'���.cck-es �l tract -dor ��ir�l_e_r_ <br />+,r,Acks Scram is 1D_ut!Ab_ FGGlk�sj u-ses LA>vlsatJc—ire A <br />nspection Form Included: Q t Lv'7f <br />Comments Included:`�+—� <br />sines, R�Slur, Phone Number In or's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Co rect: I correct: (� X A All P L E' <br />■ White Copy CIWM Yellow Copy Operator Pink Copy. LEA ® ■ <br />