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Waste Tire Arty & Inspection Rep • Inspection Report Number <br />■ �� State of California I 1 - 1127711 <br />CIWMB 181(New 04/04) Survey Form -Page 1 <br />California Integrated Waste Management Board <br />BLUE OR BLACK INK PEN <br />Part A - Survey <br />Business Profile Inspection Details <br />TPID - I Inspection Type (Fill one) <br />Site Suffix: �y 1 ri 5 l ® Routine Q Re -inspection Q Referral Q Observation <br />Local C If Referral, choose referral type (Fill one) <br />Identifier:( I,0 . 1.� f1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By I Inspector <br />LkN I S T 1 k' C--�U v! CP- <br />Physical Address `j !j <br />Inspection Date ® 11 <br />Time In Time Out <br />Business Rep Title AM(, AM <br />' • PM v ® PM <br />pec k lcj)� h urs 9� C <br />114 T' T P..1.... Role Storage Type <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair <br />40 Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />-- - <br />q \ <br />U <br />Operational atus <br />(Fill one only) <br />Ire ype <br />(Fill all that apply) <br />us <br />(Fill all that apply) <br />(Fill all that apply) <br />Q Other <br />® Active <br />0 Passenger <br />Generator <br />Outdoor <br />0 <br />0 Closed <br />Q Altered <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Hauler <br />Indoor <br />O <br />Q Inactive <br />i Truck <br />Other: § <br />Q Planned <br />40 OTR <br />O End-use <br />Container <br />U Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />Q Government <br />Q Retreader <br />Q Collection <br />Q Crumb Rubber <br />Q Shredder <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A I <br />HAULING AND MANIFEST REQUIREMENTS <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Other: § <br />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m/IT/m <br />(Required for NOV or EX7) <br />Q Referred / CIWMB Enforcement <br />® In Compliance - No Violations <br />CommentsQQ 1Clr I ANS 1C. 'iI f 9— k m%e(__�_�or% OeM2� CA` 115 aaL l�nU� WAS 1 <br />�10 <br />nspection Form Included: <br />Comments Included: <br />INSTRUCTIONS <br />_A_ f/-/_ <br />Number <br />%rc- <br />Signaturehone Number <br />N BACK Correct:* <br />White Copy: CIWMB <br />Incorrect: \Z (; <br />X <br />A <br />2 <br />62081 <br />■ <br />Pink py: LE <br />Yellow Copy: Operator <br />