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-E@g Waste Tire SffWy & Inspection Repo Inspection Report Number ■ <br />�i State of California T 1 - 1143817 <br />CIWMB181 <br />Waste <br />eManag) Survey Form - Rage 1 <br />:'art <br />California lntegratedWasteManagementBoard BLUE OR BI -ACK INK PEN <br />art A - Survey _ _ <br />Business Profile <br />Site Suffix: � J � � lir S a <br />Local <br />Identifier: Sa () g0(.Lq 1,11 n GA��j <br />Business or Facility Name <br />_T�\ Ce u Tl. W C4A 'C-, QA <br />Physical Address <br />Business Rep �n Title <br />0r <br />Tire Count (Whole/PTE) 5 <br />O <br />GPS Latitude , <br />O <br />Longitude - <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair <br />Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />Inspection Details <br />Inspection Type (Fill one) <br />Routine ® Re -inspection Q Referral Q Observation <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 i - 1 0 1 gU) &14o <br />Inspection Date / 0 / 1 b <br />Time In Time Out <br />.o of 0 AM a U 0 AM <br />0 PM I lJ 0 PM <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 />® Active <br />40 Passenger <br />O Generator <br />® Outdoor <br />Q Closed <br />Q Altered <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 Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Agriculture Q Shredder Q Other <br />ENFORCEMENT STATUS <br />® Notice Of Violation Q Extension <br />Compliance Deadline <br />Date M / 16111 / FN <br />(Required for NOV or EXT) <br />Q Referred I CIWMB Enforcement <br />Q In Compliance - No Violations <br />i <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V� <br />A <br />rHAULING 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 />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 />_ <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />Other: § <br />Comments PrQ\I1"0Lt3 i( 1, or, Ll'Alm-v,& (u) 1a. 110 . 1 <br />nspection Form Included: ® y <br />Comments Included -0 - - --r�U' -07 <br />_B s ness R 's Si ature . Phone Number <br />INSTRUCTIONS ON BACK Correcttr♦ Incorrect: X Ci <br />■ White Copy: CIWMB Yellow Copy: Operator <br />Inspe4or's Signature - <br />A _ P 1 23 <br />Pink C LAIC <br />n4 <br />rM_M <br />Phone Number <br />62081 <br />® ■ <br />