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a;9Waste Tire Ne & Inspection Re o <br /># Inspection Report Number <br />State California <br />CIWMB181 <br />I 1- 1141040 <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) j <br />Site Suffix: L Il ® Routine 0 Re -inspection 0 Referral 0 Observation <br />Local ^ If Referral, choose referral type (Fill one) <br />Identifier: J Q wl /1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />u <br />Physical Address 3 1 - 1 Q < n FJ'-ORU <br />Inspection Date <br />On � I <br />Business Rep Title <br />C /1 g5aIII 5 <br />4k(,Jl. &_tL?Tc,�n ,, .Aninq" IL'(,h' <br />Tire Count (Whole/PTE) L4 D <br />GPS Latitude <br />Eel <br />Longitude - <br />Business Type (Fill all that apply) <br />Time In <br />Time Out <br />' <br />/� Q AM <br />a I <br />0 AM <br />V PM <br />{ <br />PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Fill one only) <br />( y) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />40 Active <br />0 Passenger <br />® Generator <br />0 Outdoor <br />0 Closed <br />0 Altered <br />j <br />0 Hauler <br />Indoor <br />0 Inactive <br />® Truck <br />0 Planned <br />0 OTR <br />0 End -Use <br />! 0 Container <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 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 1 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 1 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 />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n i n Other: § <br />Comments <br />�Jjlo) UQ 60- T1 <br />0 Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />— - <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 />f �Lli�v Ltc {ins 0 f u teNs Of �r)c-f(I . - <br />nspection Form Included: 0 �56,,41,�s <br />' /J �f�'jGy r[ / y • Q U �[ <br />Comments Included: -((6,���jL v T-�U��In ors Si naturBuignature Phone Number sp g e. Phone Number <br />v -- <br />INSTRUCTIONS ON BACK Correct: * Incorrect: X � .. A M ! �1213162081 <br />0 White Copy: CIWMB Yellow Copy: Operator Pink Copk- LE 0 <br />