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Waste Tire SuSby & Inspection Report* 'pection Report Number <br />State of California <br />'M 181 New 04/04) y - �y Survey Form Page 1 I 1- 1141229 <br />CIWMB ( <br />California Integrated Waste Management Board 4 <br />� <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />� <br />Site Suffix: i i �j j ,•_ ,,,_, Jam? ,_ t 0 Routine 0 Re -inspection <br />0 Referral 0 Observation <br />Local ( If Referral, choose referral type (Fill one) <br />Identifier: �`� i�A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By <br />Physical Address-" C ? /l <br />Inspector <br />__ _ <br />_......_._._...._.. <br />......_._..............._.................................. ....... ._....._............-......._........... <br />Street <br />0 <br />I / <br />Inspection Date <br />0 <br />0 <br />Business Rep <br />Stat <br />Title <br />Time In <br />I 0 AM� <br />Time Out <br />! ; AM <br />0 <br />0 <br />Mr <br />0 <br />i <br />0 P <br />Tire Count Whole/PTEA <br />0 <br />I I <br />Operational Status Tire Type <br />(Fill one only) {F Ili all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />;F111 all that apply} <br />s <br />0 <br />j <br />0 Active 0 Passenger <br />0 Generator <br />0 Outdoor <br />e ���--�•� <br />GPS Latitud�..: • �_ � <br />0 Closed D Altered <br />0 Hauler <br />0 indoor <br />Other: § , <br />Inactive 0 Truck <br />Longitude <br />0 Planned 0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply} <br />�nN- <br />. �.,.., <br />0 New Tire Dealer 0 Auto Repair <br />0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 <br />Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body <br />0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler <br />0 Agriculture <br />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 />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 - 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 />Comments <br />- <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date IE/m/m <br />( Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />—ACS `'-' V��C-, CL r s <br />e <br />._....... - -- <br />Inspection Form Included: 0 <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspector's SignaturePftone number <br />X 62081 <br />INSTRUCTIONS ON BACK Correct:* Incorrect: „, I_ <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />