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■__� este Tire Sutry 8t I11SpeCt1O11 RepOrt,, nspection-Report Number . ; <br />Lcia <br />S to of California <br />Survey Form - Page 1 1 I- 10 7 2 4 0 <br />C1WM8 181 New 04104). <br />Califomia Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details . <br />TPID - Inspection Type (Fill one) <br />Site Suffix: �# �I t% t r Q Routine Q Re -inspection Q Referral Q Observation. <br />Local f W If Referral, choose referral type (Fill one) <br />Identifier: a ► t T( ),(�� ��l t yt.. ( Q CHP Q CIWMB Q Complaint Q Educational Visit. Q Other <br />tj <br />Business or Facility Name ( Nit) ��- Inspected By Inspector . <br />(Physical Address Cf I f ( () �f �•(ii ✓t,trGf <br />Street <br />Inspection Date <br />I Stock 10k,� G I S�y <br />City I State ZIP Code Time In Time Out <br />Business Rep Title AM EE m O AM <br />O <br />t r PM O PM <br />Rid( , fU tit FV0 4!10 A-1 <br />Operational Status, Tire Type Business Role Storage Type <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />Tire Count (Whole/PTE) a O <br />Q_ Active 0 Passenger (D Generator. Q Outdoor <br />GPS Latitude \ 0. Q Closed Q\Altered <br />m . Q Hauler �� Indoor <br />Q Inactive Q Truck <br />�Q Planned Q OTRLongitude QEnd-Use Q <br />Container ner <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet (K) Government Q Retreader <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder :. Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A i <br />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 />n <br />n <br />Other: <br />Comments <br />f to <br />I ..i- L�_,, <br />l <br />Dismantler Q Tire Derived Fuel <br />i <br />ENFORCEMENT STATUS <br />3 Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q In Compliance - No Violations. <br />nspection Form Included Q' <br />Comments Included: Q _ ------.. <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />• 62081 <br />INSTRUCTIONS ON.BAGK Cormt: Incorrect: ) �/ .fl�i ,. . <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA r/� L ■ <br />f <br />