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=_ Waste Tire Sulk & Inspection Report spection Report Number <br />State CIWMB California I l- 114 0 8 6 5 <br />grated 1st(New Manage Survey Form - Page 1 <br />California Integrated Waste Management Board <br />'art A - Survey _ BLUE OR BLACK INK PEN_ <br />Business Profile Inspection Details <br />TPID -Inspection ( Inspection Type (Fill one) <br />Site Suffix: U <br />®Routine Q Re -inspection 0 Referral Q Observation <br />Local <br />Identifier: <br />Business or Facility Name n <br />re ca_s <br />Physical Ad ress <br />G((�C) j �l <br />Business Rep <br />Tire Count (Whole/PTE) <br />SPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />O New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />CA q s2t1-5 <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />Inspection Date Ci I <br />Time In <br />/ 1 1 / l <br />Time Out <br />Title <br />H 58 � �a�-c�l: n • <br />� <br />1 -- <br />Operational Status <br />(Fill one only) <br />� ®AM <br />-----0 PM -- <br />Tire Type <br />(Fill all that apply) <br />i � � <br />Business Role <br />(Fill all that apply) <br />� Q AM <br />--- 0 PM <br />Storage Type <br />(Fill all that apply) <br />— -- <br />„[ <br />- ---.- <br />PRC § 42951 - Waste Tire Hauler Registration and Transport- ..... of Tires <br />Q Active <br />® Closed <br />Q Passenger <br />Q Altered <br />O Generator <br />Q Outdoor <br />O <br />-- - ---- <br />O <br />O Inactive <br />Q Truck <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />Q <br />0 Planned <br />O OTR <br />O End -Use <br />Q Container <br />U Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />U Government <br />0 Collection <br />Q Shredder <br />Retreader Q Dismantler OT" -Derived Fuel <br />Q Crumb Rubber <br />• Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />AHAULING <br />_ ...... AND MANIFEST REQUIREMENTS <br />0 <br />Q <br />- ---.- <br />PRC § 42951 - Waste Tire Hauler Registration and Transport- ..... of Tires <br />O <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive 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 />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § <br />ENFORCEMENT STATUS <br />O Notice Of Violation 0 Extension <br />Compliance Deadline <br />II <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />® In Compliance - No Violations <br />Comments <br />Ail <br />Inspection Form Included: O <br />Comments Included: 0' Septiness Rep's ign ure Phone Number Ir <br />INSTRUCTIONS ON BACK Correct: Incorrect: X A , <br />White Copy: CIWMB Yellow Copy: Operator Pink <br />167-a`7 ) qa -� <br />Phone Number <br />62081 <br />