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i Waste Tire Sufty & Inspection Repore Inspection Report Number <br />State oCJWMBf California <br />Lj(jj <br />California Int 7 grated'WasNe Management Board Survey Form - Page 1 I t - 1 0 7 2 7 8 <br />Part A - Survey BLUE OR BLACK INK PEN_ <br />Inspection Details <br />l <br />� TPID - � I � n I } / I � I � %I � / Inspection Type (Fill one) <br />Site Suffix: L7 11 Clll/ I 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />i Identifier: t L)AI 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name LI Inspected By Inspector <br />Iv_ Y�,-ter I1C)l <br />Physical Address <br />Street � A C�� f\\[ I 1 1 I <br />Inspection Dat( <br /><z., Inspection <br />L -Fbn CA G5206, 1 <br />Citti State ZIP C de Time In <br />Business Rep Title <br />Ii - <br />- Operational Status <br />Tire Count (Whole/PTE) (Fill one only) <br />® Active <br />m 11O 0 Closed <br />GPS Latitude <br />_ O inactive <br />Longitude — Planned <br />MMENNUMN, <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair © Trucking Fleet 0 Government 0 Retreader <br />0 Used 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 Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 (Other: § <br />Comments <br />j <br />J- Aim r <br />0 Dismantler 0 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 />0 In Compliance - No Violations <br />YY � - <br />/�YJ�JPC{ /Vt' V/ri�L�T/�t �' :,7 / A)E'./1 J5 A)0 <br />Inspection Form Included: 0 <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X �, ',/ L X i A Mj P , � I L , I 1 ; c j . 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />Time Out <br />��AM <br />0 A <br />OPM <br />0 P <br />— <br />Tire Type <br />Business Role <br />_- <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Passenger <br />0 Generator 0 Outdoor <br />Altered <br />0 Hauler <br />0 Indoor <br />0 Truck <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair © Trucking Fleet 0 Government 0 Retreader <br />0 Used 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 Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 (Other: § <br />Comments <br />j <br />J- Aim r <br />0 Dismantler 0 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 />0 In Compliance - No Violations <br />YY � - <br />/�YJ�JPC{ /Vt' V/ri�L�T/�t �' :,7 / A)E'./1 J5 A)0 <br />Inspection Form Included: 0 <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X �, ',/ L X i A Mj P , � I L , I 1 ; c j . 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />