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Waste Tire Su► Jy & Inspection Report Inspection Report Number <br />• • •'�� State of CaliforniaC JWMB 181 04/04) <br />California Integrated Was eeManagement Board Survey Form - Page 1 T 1 <br />i 1 1140615 <br />PartA - Survey - BLUE OR BLACK INK PEN <br />Business Profile Inspection Details - <br />TPID - Inspection Type (Fill one) <br />Site Suffix: 3 9 7 Z ® (9 Routine Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: 11 v,. a,.>-�„ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />Physical Address <br />b ti ;F VQ. �t vva--* S+. <br />S i -c c.k.;-� <br />Business Rep <br />�ru�r.'k /�uLrO <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />CA r s3 <br />Title <br />O <br />0 <br />Inspection Date ` O / f / <br />Time In Time Out <br />Longitude – <br />0 AM <br />V t <br />0 PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill all that apply) <br />® Active <br />® Passenger <br />Q Closed <br />Q Altered <br />Q Inactive <br />Q Truck <br />Longitude – <br />® AM <br />J <br />f <br />QPM <br />Business Role <br />Storage Type <br />(Fill all that apply) ! (Fill all that apply) <br />® Generator <br />® Outdoor <br />Q Hauler <br />i <br />Indoor <br />Longitude – <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br />J _ <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />JENFORCEMENTSTATUS _ <br />V A -l' HAULING AND MANIFEST REQUIREMENTS <br />— - -- - --- — <br />Q O PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />m <br />/ <br />m <br />/ <br />m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />Q <br />Q <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 Referred ! CIWMB Enforcement <br />Q Q 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br />Q 0 Other: § <br />Comments Y% <br />l ked :- <br />nspection Form Included: Q <br />Comments Included: S - <br />Business Rep's Signature <br />INSTRUCTIONS ON BACK Correct: <br />White Copy: CIWMB <br />P one Number / <br />Incorrect: X � ',/. <br />Yellow Copy: Operator <br />Pink <br />62081 <br />