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y <br />Waste Tire Su*y0 Inspection ReportOlnlation Report Number <br />State of California I R jl <br />CIWMB181(New04104) Survey Form - Page 1 i 1 - 1 0 L 5 n 4 3 <br />— <br />California Integrated Waste Management Board -- - <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -- � I Inspection Type (Fill one) <br />Site Suffix: W 41 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local C ) I If Referral, choose referral type (Fill one) <br />Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name <br />r h <br />IiJ✓ _0 i <br />Physical Address <br />i1 r1 ay� <br />Street <br />I S10Ck to Pl I ('A c:j5 20(o <br />Citv State ZIP Code <br />Business Rep Title <br />'All C rN CJI c <br />Tire Count (Whole/P <br />�Vt a I, k, t <br />I t f Q Y I <br />,0 <br />O <br />Inspected By <br />((- i aF11 <br />Inspector <br />Inspection Date <br />Time In Time Out <br />F T] 0 PM m'm 0 P <br />0 AM 0 AM <br />Operational Status Ire Type' <br />Business Role <br />orage Type <br />(Fill one only) Fill all that apply) <br />(Fill all that apply) <br />ill all that apply) <br />(a Active 0 Passenger <br />0 Generator <br />Outdoor <br />0 Closed 0 Altered <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 Hauler <br />door <br />0 Inactive 0 Truck <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 Planned 6OTR <br />0 End -Use <br />ontainer <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />lent <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder <br />0 Retreader <br />0 Crumb Rubber <br />0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V I A H ULING 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 />It <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire 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 />0 Dismantler 0 Tire Derived Fuel <br />_ I <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 I CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments � rfctt 'I f (er (� IF UtJCt t /(�E (!'v ) s 1 (Z u I� �i� � hf �'%1'�{ fr� `f I. ( ✓ <br />,,"t>r . Vs, re ��5 re Sole fo (�t.fs,l�rkle�`i duryin� cFuank 11F <br />�fru01 i1 C/- UJ(e ' i S If jbLA 0k7Ct CF14 d no� <br />Gjt <br />-1116- -- <br />nspection Form Included: 0 <br />Comments Included: 0 <br />Business Rep's Signature <br />INSTRUCTIONS ON BACK Correct <br />White Copy: CIWMB <br />Phone Number Inspector's Signature Phone Number <br />620£31 <br />Incorrect: X = , IvilIPILIE1 11 C 31 <br />Yellow Copy: Operator Pink Copy: LEA <br />