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ction Report Number <br />Waste Tire Su. & Inspection Repor Sp <br />e <br />®iZwil State of California <br />Cgrated Waste <br />eManag) Survey Form - Page 1 i -7 - 1 0 1 3 4 5 2 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - ` Inspection Type (Fill one) <br />Site Suffix: I 1 -gj I C 't - I3 I .) <br />'T � Routine 0 Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier: <br />Business or Facility Name <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint <br />0 Educational Visit 0 Other <br />Inspected By Inspector <br />O <br />Physical Address <br />- <br />r: r ;V j <br />-� <br />i <br />Inspection Date <br />I <br />- <br />State <br />Business Rep Title <br />ZIP Code <br />Time In <br />l - n O AM <br />Time Out <br />O AM <br />_ Y lam. s•�. �r,Jr G-� <br />PM <br />0 PM <br />j I <br />Operational Status "'fire Type <br />Business Role Storage Type <br />Tire Count (Whole/PTE} <br />(Fill one only) (Fill all that apply) <br />� <br />(Fill all that apply) (Fill all that apply) <br />' <br />@ Active 0 Passenger <br />0 Generator 0 Outdoor <br />O 0 Closed 0 Altered <br />� pS Latitude j � . � t <br />L 1_� <br />Hauler Indoor <br />0 Inactive 0 Truck <br />Longitude - <br />D <br />Planned 0 OTR <br />J <br />0 End -Use 0 Container <br />Business Type (Fill all t <br />6t app y) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture <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 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 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Manifest Forms and Tire 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 / V 'n e, <br />;J✓r �fi (' Cf,✓ i �?c� tet-" /S � • � S <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 />Tor <br />" <br />�." w _.� <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:0 Incorrect: X %, E X A ,af P I L I El It 1213 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />