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'� == Waste Tire Sup . ay & Inspection Report Inspection Report Number ■ <br />Y:a <br />rti State CIWMB California I 1- 114 0 6 2 7 <br />grated Waste <br />eManag) Survey Form - Page 1 <br />California Integrated Waste Management Board <br />t A -Survey -_ BLUE OR BLACK INK PEN <br />ness Profile Inspection Details - <br />riD - © Inspection Type (Fill one) <br />d <br />Site Suffix: �j l� S J (a Routine 0 Re -inspection 0 Referral 0 Observation <br />LocalIf Referral, choose referral type (Fill one) <br />Identifier: ISGln J GG lAi l' C 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facil'ty Name 1 Inspected By <br />N;C,, c MtorCV�2. - <br />Physical Address 31 <br />r„ry Ave . <br />y <br />L,A\( o e CA `151N <br />Business Rep N11 b t tA Title <br />L�u1 U <br />n?;SI✓ 2ais Cc�, r <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />30 <br />O <br />Inspector <br />6 1 & Es4t(; <br />Inspection Date <br />` <br />Time In <br />Jsed <br />11 <br />3 • "1 <br />'l O AM <br />Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />v QPM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill all that apply) <br />0 Active <br />0 Passenger <br />e Closed <br />0 Altered <br />0 Inactive <br />® Truck <br />0 Planned <br />0 OTR <br />Comments _T <br />Time Out <br />Vew Tire Dealer 0 Auto Repair IP Trucking Fleet U Government U Retreader <br />Jsed <br />Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 <br />Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V I <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 -Manifest System Requirements for -Tire Dealers or Waste Tire Generators - <br />n <br />n <br />Other: § <br />Comments _T <br />Time Out <br />DAM <br />Sl.� PM <br />Business Role <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Generator <br />• Outdoor <br />0 Hauler <br />0 Indoor <br />0 End -Use <br />0 Container <br />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 />0 <br />,.._,section Form Included:01 <br />4441 <br />(,f�g 3 /8 <br />Comments Included: - - - -- <br />Business Rep's Signature Phone Number 41nspt.r's Signature Phone Number <br />-- ---------..-..-...- <br />INSTRUCTIONS ON BACK If Correct: Incorrect: I I 62081 <br />� ���..����A�I3I��; lid <br />■ White - - --- -- w -- — -. -' ® ■ <br />Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />