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Inspection Report Number <br />Waste Tire Su -y & Inspection Repor <br />LSi`I� State of California _CIWMB 181 (Nrpt � <br />California Integrated Was eeManagelment Board Survey Form - Page 1 + f <br />- Survey BLUE OR BLACK INK PEN <br />Site Suffix: <br />Local <br />Identifier: <br />Business or Facility Name <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Inspected By <br />Q <br />Inspector <br />Physical Address <br />AAA Cc,, <br />I <br />- 1 <br />J <br />— � � / <br />I I I, IA rzi � >� - <br />Q <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Street <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Inspection <br />Date / <br />L (✓, <br />�.5'ryC % <br />Tn� CA <br />�5-ZU�i <br />O <br />O <br />Other: § _ <br />City <br />Business Rep <br />State <br />Title <br />ZIP Code <br />Time In <br />AM <br />Time Out <br />O AM <br />FQPM <br />m'� QPM <br />Operational Status <br />Tire Type <br />Business Role Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) (Fill all that apply) <br />QActive <br />Q Passenger <br />Q Generator Q Outdoor <br />Latitude <br />GP$ <br />O O Closed <br />Q Altered <br />Hauler Q Indoor <br />i <br />_ i1I <br />O .6) Inactive <br />Q Truck <br />Lon g Rude <br />— <br />Q Planned <br />Q OTR <br />O End Use Q Container <br />usiness Type (Fill all that apply) <br />Q New Tire Dealer <br />Q Auto Repair Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler <br />Q Tire Derived Fuel <br />Q Used Tire Dealer <br />Q Auto Body Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station <br />Q Hauler Q Agriculture <br />Q Shredder (S Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />O <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 <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />O <br />Other: § _ <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />Comments <br />Ay A)s ®a rrf < - 411,0AC-IV I A A4 7-3r t IJ 4- 1.) A o (%ia/' 1,JA T� <br />Inspection Form Included: Q' la <br />Comments Included: Q - — -- - -� <br />Business Rep's Sign ure Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X <br />White Copy: CIWMB Yellow Copy: Operator <br />Inspector's Signature Phone Number <br />�{ ,�l �i P ` I _ � � � • 62081 <br />Pink Copy: LEA <br />