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® _ ° Waste Tire SL4% & Inspection Reporme-pection Report Number <br />State of California <br />CIWMB <br />grated Waste <br />eManag) Survey Form - Page 1 Il - 1127865 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID-\� Q 10 <br />s �� ! Inspection Type (Fill one) <br />Site Suffix: / ® Routine Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier:y� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected B <br />- P Y Inspector <br />Physical Address <br />Business Rep Title <br />Tire Count (Whole/PTE) q3 <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />Q New Tire Dealer ® Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />on <br />O <br />Inspection Date / <br />Time In <br />f iJ Q <br />® AM <br />Q PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill all that apply) <br />. Active <br />® Passenger <br />Q Closed <br />Q Altered <br />Q Inactive <br />Q Truck <br />O Planned <br />Q OTR <br />Q Trucking Fleet <br />Q Government <br />Q Car Dealer <br />Q Collection <br />Q Agriculture <br />Q Shredder <br />Q Retreader <br />Q Crumb Rubber <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V 1 A HAULING AND MANIFEST REQUIREMENTS <br />b <br />Time Out <br />l G CAM <br />` O PM <br />Business Role <br />(Fill all that apply) <br />® Generator <br />Storage Type <br />(Fill all that apply) <br />Q Outdoor <br />Q Hauler ® Indoor <br />Q End -Use Container <br />Q) Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Q <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />Q <br />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 m / m / m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />C) <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />C) <br />14 CCR 18459.3 -Retention of Comprehensive Trip Logs for 3 years <br />lC) <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CIWMB Enforcement <br />0 <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />lC) <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />In Compliance - No Violations <br />Q <br />Other: § <br />Comments T� L,i f 0,4� <br />l�1.��7�1C, %/I�I.'L�o�,'c�h� h�!!�"t1 —11� <br />,Inspection Form Included: ® <br />Comments Included: <br />AInss s Signature Phone Number <br />INSTRUCTIONS Orrect: Incorrect: X 5 <br />White Copy: CIWMB Yellow Copy: Operator <br />Pink <br />nature Phone Number <br />62081 <br />