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jjWaste Tlr Su'r & Inspection ReportIspection Report Number <br />State of California x <br />CIWMB 181 (New 04104) SUrVey Form -Page 1 ��- - Q i3 X3:2 7 <br />California Integrated Waste Management Board <br />'art A - Survev '� BLUE OR BLACK INK PEN <br />Profile <br />TPID - <br />Site Suffix: <br />{-_-71 q � <br />Inspection Details <br />l Inspection Type (Fill one) <br />O Routine Q Re -inspection 0 Referral @ Observation <br />Local <br />V <br />; A I <br />If Referral, choose referral type (Fill one) <br />Identifier: <br />�,- "^'--' <br />^ } G_Nl <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires - <br />O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name -i. <br />0 <br />s <br />Inspected By <br />- -- — <br />Inspector <br />O <br />`'�'' <br />Q <br />Q <br />Gi Y r� �I C• -'t^ <br />�' S <br />Physical Address <br />O <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Inspection <br />Date (� <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Street <br />/✓ <br />O <br />I + 'fir �� � (r, %�' <br />� � �.—d j <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />- 7. _- <br />City <br />Business Rep Title <br />State ZIP Code <br />Time In <br />AM <br />Time Out <br />Q AM <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />K�: <br />OPM <br />m'm 0 P <br />Tire Count (Whole/PTE) <br />_jl <br />m-� <br />-Z <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />I <br />1 <br />1 f ® <br />Active <br />> Passenger <br />® Generator <br />Outdoor <br />D <br />Q Closed <br />0, Altered <br />GPS Latitude <br />m <br />,,. <br />0 Hauler <br />0 Indoor <br />Q Inactive <br />Truck <br />D <br />Longitude - <br />7T� • <br />O Planned <br />; OTR <br />Q End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <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 (0 Other l 1'7c <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 />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires - <br />O <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <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 />f) In Compliance - No Violations <br />Comments <__ % <br />Inspection Form Included: 01' <br />Comments Included: 0' �- <br />Business Reps Signature Phone Number Inspector's Signature Phone Number <br />F <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X w' E IY rM'� '� e Ti 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />