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M jWaste Tire Suky & Inspection Rep Inspection Report Number <br />State CIWMB California I 1 181 (ew 04104)- 1141035 <br />California Integrated Waste Management Board Survey Form - Page 1 <br />Part A - Survey - - BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -� � 0 � O I Inspection Type (Fill one) <br />Site Suffix: 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local �' If Referral, choose referral type (Fill one) <br />Identifier: Sj� n V a ��� C(PA0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />- — <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Ad <br />�S-7SS <br />0h <br />1 foA "1533f)Inspection DateC <br />Time In Time Out <br />Business Rep TitleO AM 1 ,� S 0 AM <br />' 0 V <br />9 PM � PM <br />V,arniro G0fNS41_L irv�na.nca- <br />Operational Status Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE)(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />f ® Active 41 Passenger Generator ® Outdoor <br />O 0 Closed 0 Altered <br />GPS Latitude 0 Hauler 0 Indoor <br />O 0 Inactive � Truck i <br />Longitude – 0 Planned ® OTR 0 End -Use 0 Container <br />Business Type (Fill all that apply) <br />U New Tire Dealer U Auto Repair U Trucking Fleet d Government U Retreader <br />0 Used <br />Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use <br />V <br />A <br />-Facility <br />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 />® <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 is <br />Dismantler () Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred /CIWMB Enforcement <br />In Compliance - No Violations <br />- -- ----- --- ----- ------ <br />Inspection Form Included: 0 <br />Comments Included: ���'�Caa �/ %'p�- 4��3 �U�J 6FlU`31 ! • <br />Business Rep's Signature Phone Number Inspect ignatur Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect:62081 <br />C <br />- - `/ I' <br />■ White Copy: CIWMB Yellow Copy: Operator Pink C Wp <br />® ■ <br />