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i Waste Tire Sur y & Inspection Report spection Report Number <br />State of California <br />C WMB 181 (New 04104) <br />California Integrated Waste Management Board Survey Form - Page 1 11 - 1140873 <br />Part A - Survey - _ _ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection _ C ' Inspection Type (Fill one) <br />Site Suffix: ® Routine Q Re -ins ection Q Referral Q Observation <br />Local <br />Identifier: Stns - T.Gu i ✓t <br />Business or Facility Name " <br />Physical Address <br />i -i 4 l/J , ISO n VAI r J <br />I <br />S+&+«G' CA `t_S2) s - <br />Business Rep <br />kr t; ,k 7-tru .tel l <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Tvne /Fill all that nnnlvl. <br />Title <br />P <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 />3 t o r Ahytda Foe4- acv,-. <br />Inspection Date <br />Time In <br />`, 0 AM <br />I S PM <br />U New Tire Dealer <br />U Auto Repair <br />U Trucking Fleet <br />tom• <br />- <br />Operational Status <br />-- <br />Tire Type <br />Q Auto Body <br />2 <br />(Fill one only) <br />(Fill all that apply) <br />Q Service Station <br />® Active <br />® Passenger <br />O <br />Q Closed <br />Q Altered <br />O <br />Q Inactive <br />Q Truck <br />Q <br />Q Planned <br />Q OTR <br />U New Tire Dealer <br />U Auto Repair <br />U Trucking Fleet <br />® 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 <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <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 />a(l I <br />Time Out <br />SAM <br />® PM <br />Business Role <br />(Fill all that apply) <br />I® Generator <br />Q Hauler <br />Q End -Use <br />Storage Type <br />(Fill all that apply) <br />® Outdoor <br />(a Indoor <br />Q Container <br />Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />In Compliance No Violations <br />Comments <br />Axk)i Jk 41.�.1 r <br />WICLS 14 <br />Inspection Form Included: Q nn <br />-at: Z__3Comments Included: <br />I� Czp9 6� <br />Business Rep's Signa re Phone Number spector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: ,� i 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Cop : LE <br />