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= g Waste Tire Su ,y & Inspection Report Inspection Report Number <br />F' State of California <br />CIWMB181 <br />Waste <br />eManag) Survey Form - Page 1 Il - 1140894 <br />California Integrated Waste Management Board <br />Part A- Survev BLUE OR BLACK INK PEN <br />Business Profile [inspection Details <br />Site Suffix: <br />3 V - o <br />Local <br />Identifier: �� v��rv✓ �r�.�-c� <br />Business or Facility Name P <br />Physical Address <br />la yo <br />5'kue�rrr <br />Business Rep <br />Tire Count (Whole/PTE) <br />GpS Latitude <br />(A 15..706 <br />Title <br />Are / 7 �% <br />. <br />0 S7 <br />0 <br />O <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <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 />Inspection Date <br />V <br />3 / <br />J v <br />Time In <br />O <br />Time Out <br />Q <br />` & <br />40 AM <br />o2 Q <br />0 AM <br />G <br />PRC § 42956 - Registration/Decal in Vehicle <br />O PM <br />Q <br />® PM <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 />Q Passenger <br />® Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q Hauler <br />Indoor <br />Q Inactive <br />® Truck <br />Longitude - 10 Planned Q OTR i Q End -Use I Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader <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 />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />O <br />_ ----..... _....-_ .......---:._.. . _ ....... _..._ _.__.:.. <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <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 />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 />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 <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments <br />Q Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />I <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q In Compliance - No Violations <br />Inspection Form Included: 0, <br />Comments Included: ® <br />usi ss s Sig a re Phone Number lKspectoes. Signature Phone Number <br />i �� 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: X. ]AM p � _L`_ 2 3 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: EA <br />