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a <br />Liz Waste Tire Si l y & Inspection Repor"tspection Report Number <br />State B California Survey Form - Page 1 I- 1140858 <br />CIWMB 181 (New nage) ry <br />California Integrated Waste Management Board y <br />'art A -.Survey _ BLUE OR BLACK INK PEN <br />Business Profile I Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: I <br />®Routine Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />V <br />Physical Address 3 — d ` A <br />I I I q Cj ,N <br />L c) Ct <br />Business Rep <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />0 <br />C'A -2 S Z'f <br />Title <br />ska� <br />U New Tire Dealer <br />Q Auto Repair <br />Y�iLG-CutCk�:'r�%f� <br />Inspection Date <br />Q Retreader <br />Q Used Tire Dealer <br />Q Auto Body <br />Time In <br />Q Collection <br />Time Out <br />Q Service Station <br />t Z 4 <br />QAMj <br />d <br />C I <br />QAM <br />S <br />Q <br />® PM <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <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 />a Outdoor <br />Q Closed <br />Q Altered <br />Comments <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />® Truck <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />U New Tire Dealer <br />Q Auto Repair <br />® Trucking Fleet <br />Q Government <br />Q Retreader <br />Q Used Tire Dealer <br />Q Auto Body <br />Q Car Dealer <br />Q Collection <br />Q Crumb Rubber <br />Q Service Station <br />Q Hauler <br />Q Agriculture <br />Q Shredder <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A I HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <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 />010 <br />1 Other: § <br />Comments <br />Inspection Form Included: <br />Comments Included: <br />Q Dismantler Q Tire Derived Fuel <br />IENFORCEMENT`STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date <br />m/m�m <br />(Required for NOV or EXT <br />Q Referred / CIWMB Enforcement <br />L _-[ <br />L In Compliance - No Violations <br />ffit — 0 (6 2- <br />i awsmess p's signature Phone Number Inspector's Signature Phone Number, <br />INSTRUCTIONS ON BACKCtsrrer+r����� �'� �� � J � . �.� 2 3 62081 <br />®® ■ <br />White Copy: CIWMB Yellow Copy: Operator Pink Co V <br />