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i 0 <br />Waste Tire Survey & Inspection Report Inspection Report Number ■ <br />Slate of California Survey Form -Page 1 f 8-1025795 <br />CIWMB 181 New 041041 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />(Business Profile I Inspection Details <br />TPID -7 p v Inspection Type (Fill one) <br />3 Site Suffix: L- g / Z -7 0 Routine Q Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier: <br />Business or Facility Name <br />\j -PL lra�r��U.— �- <br />Physical Address <br />1 / 1179 <br />Business Rep LL <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Title <br />03 <br />0 <br />G <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />Inspection Date 6> S, I I q l (0 g' <br />Time In Time Out <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 p:' HAULING AND MAFJIFE T REQUIR MEMT6 k <br />0 0 ; PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 O 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 § 1B460.2 - 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_1 0 Other: § <br />IBNT STATUS <br />Violation <br />iie�dilra <br />1. F <br />0 Extension <br />Comments <br />L/�i <br />Q AM <br />0 AM <br />'�c.� d��j04�!?,- C�•l <br />0 P <br />0 P <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 />9 Active <br />0 Passenger <br />® Generator <br />• Outdoor <br />0 Closed <br />0 Altered <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />0 Truck <br />0 Planned <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 0 Dismantler 0 Tire Derived Fuel <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 p:' HAULING AND MAFJIFE T REQUIR MEMT6 k <br />0 0 ; PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 O 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 § 1B460.2 - 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_1 0 Other: § <br />IBNT STATUS <br />Violation <br />iie�dilra <br />1. F <br />0 Extension <br />Comments <br />L/�i <br />l���r•� <br />/Sllr <br />'�c.� d��j04�!?,- C�•l <br />L�Irfy, L <br />Inspection Form Included: <br />Comments Included: <br />0 <br />INSTRUCTIONS <br />Ss ep's Signature Phone Number I?,tZsSIgnature Phone Number <br />.. 62081 <br />:K 1rLlT ;I <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />