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Waste Tire S& Inspection Repor spection Report Number <br />=.ate State of California <br />-� CIWMB 181 (e) Survey Form - Page 1 I 1 -1088394 <br />California Integrated WasttManagement <br />Waste Management Board <br />Part A - Survey, BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - J � � � /� f �-y _ �•-,I j I Inspection Type (Fill one) <br />Site Suffix: I J 1 I !��( (��L_I �� 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local f If Referral, choose referral type (Fill one) <br />Identifier. ,' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name_ i Inspected By Inspector <br />Physical AddTs/ 1 �(�ytvLt I YG; t1 <br />l� <br />-� rc1 arect I <br />Street <br />/_-o / 7 r (",A <br />r ? Inspection Date <br />! P \ `.A 11 tate ZIP Code I Time In Time Out v <br />Business Rep <br />Tire Count <br />GPS Latitude I I I. <br />Longitude - <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />Title i`q <br />O PM J C` O PM/&(�I 77- <br />Operational Status Tire Type Business Role Storage TypeFill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) Active 0 Passenger 0 Generator 0 Outdoor <br />0 Trucking Fleet <br />0 Car Dealer <br />0 Agriculture <br />0 Closed <br />0 Altered <br />0 Inactive <br />0 Truck <br />0 Planned <br />0 OTR <br />0 Hauler 0 Indoor <br />0 End -Use 0 Container <br />0 Government 0 Retreader 0 Dismantler <br />0 Collection 0 Crumb Rubber <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 />0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date?/m/0 <br />(Required for NOV or EXT) <br />0 Referred/ CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments<>1it /�!� >R %�i7 Q_f. - 1k—'l ` k (7r�!tl­,�j G��J <br />T rQ 5 0 Vo (1 V 11 P (f c- Gl 0 Vy-1 Sk_a 0 (e(4 Ylti r: • � cc <br />ction Form Included <br />Comments Included.- - <br />0 Business Rep's Signature Phone mber Inspec or's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* incorrect: X E XIAMIPILIEI 111213 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />