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Waste Th,; Sul „ay & Inspection Rt fort Inspection Report Number ■ <br />CIWMB1California(New 04104)I 1 — 112 7 919 <br />California Integrated Waste Management Board Survey Form - Page 1 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details — <br />TPID - ,� Inspection Type (Fill one) <br />Site Suffix: I ® Routine 0 Re -inspection 0 Referral 0 Observation <br />LocalIf Referral, choose referral type (Fill one) <br />Identifier: ��L111� l� �.� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />Physical Address L A c> YYI6Jc64-1 <br />- <br />`�bc���zm <br />Business Rep <br />_&X01716_0 � C*b --- <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />CA a5ao6 <br />Title <br />- - r�UY(�.1 � - - -- <br />■ <br />K <br />Inspection Date j <br />Time In <br />Longitude — O Planned 0 OTR <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V I A I HAULING AND MANIFEST REQUIREMENTS <br />0 O PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 .14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: § <br />Comments <br />1 1 / <br />Time Out <br />Business Role <br />(Fill all that apply) <br />I® Generator <br />0 Hauler <br />10 End -Use <br />4b AM <br />O PM <br />Storage Type <br />(Fill all that apply) <br />* Outdoor <br />O Indoor <br />0 Container <br />U Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS _ <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />Inspection Form Included: <br />p O - <br />_ 4n- ---�� �t� � Comments Included: ®'i — <br />u me a 's gnature Phone Number re Phone Number <br />62081 <br />INSTRUCTIONS ON BACK ! Correct:* Incorrect. XWhite Copy: CIWMB Yellow Copy: Operator © ■ <br />i® AM <br />0 � <br />� O PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill all that apply) <br />® Active <br />® Passenger <br />0 Closed <br />O Altered <br />O Inactive <br />0 Truck <br />Longitude — O Planned 0 OTR <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V I A I HAULING AND MANIFEST REQUIREMENTS <br />0 O PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 .14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: § <br />Comments <br />1 1 / <br />Time Out <br />Business Role <br />(Fill all that apply) <br />I® Generator <br />0 Hauler <br />10 End -Use <br />4b AM <br />O PM <br />Storage Type <br />(Fill all that apply) <br />* Outdoor <br />O Indoor <br />0 Container <br />U Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS _ <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />Inspection Form Included: <br />p O - <br />_ 4n- ---�� �t� � Comments Included: ®'i — <br />u me a 's gnature Phone Number re Phone Number <br />62081 <br />INSTRUCTIONS ON BACK ! Correct:* Incorrect. XWhite Copy: CIWMB Yellow Copy: Operator © ■ <br />