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Waste Tire Su. ky & Inspection Report Inspection Report Number <br />=iQ State B California Survey Form - Page 1 Il - 1140909 <br />CIWMB 181 (New ry <br />California Integrated Waste Management Board y <br />Part A - Survey BLUE OR BLACK INK PEN <br />- - - _ - - <br />Business Profile Inspection Details <br />TPID -u 2 r Inspection Type (Fill one) <br />Site Suffix: �l J 5 r I A Routine Q Re -ins ection Q Referral Q Observation <br />Local � <br />Identifier: <br />Business or Facility Name <br />Physical Addre��11,�i3' <br />F <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 />� � <br />Inspection Date <br />�1 _33L) <br />Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader <br />Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Time In <br />Time Out <br />Business Rep <br />Title <br />a ® <br />O AM <br />0® <br />! 0 AM <br />O Z <br />fl <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />PM <br />AS PM <br />Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />- - - <br />Operational Status <br />(Fill one only) <br />YP <br />(Fill a that apply) I <br />( <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />Tire Count (Whole/PTE) <br />f ' <br />® Active <br />Q Passenger <br />Generator <br />Q Outdoor <br />o <br />Q Closed <br />Q Altered <br />Q <br />Q <br />GPS Latitude <br />Date <br />m <br />Q Hauler <br />Indoor <br />O <br />Q inactive <br />Tru <br />Q <br />Longitude - <br />114 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q Planned <br />Q OTR <br />Q End -Use Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader <br />Q Dismantler Q 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 Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V A HAULING AND MANIFEST REQUIREMENTS <br />- --- <br />Q Notice Of Violation Q Extension <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <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 />Date <br />m <br />/ <br />m <br />/ <br />m <br />Q <br />Q <br />114 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 />(Required for NOV or EXT) <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 Referred / CIWMB Enforcement <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 />• In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />- <br />Comments <br />b'Ar�t - <br />Inspection Form Included: Q y - <br />1 Comments Included: ® - - - - - ___,('�-06 2 3 <br />Business Re s Signa ure Phone Number nspector s Signature Phone Number <br />- - - — - - - - <br />INSTRUCTIONS ON BACK Correct: Incorrect: l g �X fl P 1 Z 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Coy: L i_! <br />