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r�3 <br />Waste Tire xji . ay & Inspection Rep** Inspection Report Number ■ <br />California <br />CIWMB 81 (New 04104)I 1- 112 7 9 2 0 <br />California Integrated Waste Management Board Survey Form - Page 1 <br />Part A - Survey - BLUE OR R BLACK INK PEN <br />Business Profile Inspection Details - --- <br />TPID -Inspection Type (Fill one) <br />Site Suffix: 5 �' o 6 Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier:h <br />Business or Facility Name <br />-7,—re, i 6Jyt6--1 �-:xpe � <br />Physical Address <br />Sib ��•�m <br />Business Rep <br />vtin f to <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />• New Tire Dealer Q Auto Repair Q <br />CA q�ao6 <br />Tit!9- , <br />Q <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 tit l <br />1 1 t / l l <br />Time In Time Out <br />Operational Status <br />^/ (Fill one only) <br />✓}lam/ 0 Active <br />O ® Closed <br />O Q Inactive <br />Q Planned <br />Q AM <br />Q <br />0 AM <br />O PM <br />Q <br />PM <br />Tire Type <br />Business Role r <br />Storage Type. <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Passenger <br />® Generator <br />0 Outdoor <br />Q Altered <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q Hauler <br />Q Indoor <br />Q Truck <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q OTR <br />Q End -Use <br />Q Container <br />Trucking Fleet Q Government Q Retreader <br />® 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 j A 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 />In <br />Other: § <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 />ykc Co _r' f cr_R .'tC n f5 I \ -%� Z,�-� ly`�l'LC►�JIIL\C) 'fV��IY <br />TPSYI iZ 1jK11� ,1tCt�v)tt7it?✓tC�_ G(WCi �� IJS'oZ� <br />;Inspection Form Included: Qi <br />Comments Included: Q — - - --1 0 L/40 <br />_016 <br />BuMess Rep's Signature Phone Number s E <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X % X <br />■- - -- <br />White Copy: CIWMB Yellow Copy: Operator Pink <br />ya-Q6 73 <br />Phone Number, <br />62081 <br />® ■ <br />