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Waste Tire SL & Inspection Reporw Inspection Report Number <br />Lull <br />State B California I 1 -1088461 <br />Cgrated Waste <br />Survey Form - Page 1 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile _ Inspection Details <br />TPID - x Inspection Type (Fill one) <br />Site Suffix: I I O I �TV I ® Routine 0 Re -inspection 0 Referral 0 Observation <br />LocalC� �� ` If Referral, choose referral type (Fill one) <br />Identifier: �j(!1 �, 1L�1 �t (� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name ! _ <br />Inspected By Inspector <br />Physical Address <br />I �O()n� <br />Street I 1 <br />Inspection Date <br />State ZIP Code Time In Time Out <br />Business Rep Title "\ O AM 0 AM <br />QPM 0 PM <br />O <br />Operational Status Tire Type Business Role Storage Type <br />P <br />Tire Count Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />9 Active 0 Passenger 0 Generator 0 Outdoor <br />m <br />O 0 Closed 0 Altered <br />GPS Latitude 0 Hauler 0 Indoor ' <br />O 0 Inactive 0 Truck <br />Longitude — 0 Planned 0 OTR 0 End -Use 0 Container <br />Business Type (Fill all that appy - <br />0 New Tire Dealer 0 Auto Repair ® 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 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A 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 />0 <br />0 <br />Other: § <br />Comments <br />0 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 In Compliance - No Violations <br />Inspection Form Included: 0 <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspector's Signature Rhone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X Ak V E 7T A MP L- f E 3 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />r <br />�' V <br />