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r. Waste Tire SuI ey & Inspection Report Inspection Report Number ■ <br />»= State of California <br />CIWMB I 1- 114 3 5 2 7 <br />California Integrated Waste Management Board Survey Form - Page 1 <br />PartA_Survey _ _ - _ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />® Routine Q Re -inspection <br />ection Q Observation Suffix: 5 a _J <br />Local C _ <br />Identifier: c—f✓CJ)/\, <br />Business or Facility Name <br />Physical Address <br />s�khkoyA CA �5 o <br />Business Rep Title <br />fly,' Chfekricp'n <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />:3 CI - l o � )q (6,,c> <br />Inspection Date 7 / (Y / 1 c <br />Time In Time Out <br />Q New Tire Dealer Q Auto Repair 110 Trucking Fleet U Government U Retreader <br />® AM <br />Q Service <br />@0AM <br />i <br />I 3 <br />0 0 P <br />�y <br />(/ <br />QPM <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 />® Active <br />O Passenger <br />® Generator <br />® Outdoor <br />O Closed <br />O Altered <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />® Truck <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Planned <br />O OTR <br />O End -Use <br />Q Container <br />Q New Tire Dealer Q Auto Repair 110 Trucking Fleet U Government U Retreader <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q 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 />V I <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />O <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 />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />0 <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 />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />D_ <br />0 <br />Other: § <br />Comments <br />Dismantler <br />0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />® In Compliance - No Violations <br />Inspection Form Included: Q . <br />Comments Included: ® Ls <br />6 - Bu Rep's lgnature Phone Number ec r' ignature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect X � � � � � #t �+ � � � � � 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />