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Waste Tire ey & Inspection Repo Inspection Report Number ■ <br />State of California — <br />CIWMB 181 e) Survey Form - Page 1 I1 1127718 <br />California Integrated WasttManage <br />Waste Management Board <br />Part A - Survey- _ --__ BLUE OR BLACK INK PEN <br />Business Profile ! Inspection Details <br />-- ---- ---- <br />TPID -Inspection t� S f _ ® Inspection Type (Fill one) <br />Site Suffix: ` ( (9 0 Routine Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: 541 Jottgln (OLky , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or FacilityName <br />�'IILSC\ 1 Q joflil ko(e. <br />Physical Address <br />A 0 q C . Ff crno n� <br />�,+p I , A -C\ <br />Business Rep <br />SI' . A\ <br />Title <br />Inspected By <br />3q-[ <br />C9�xs Inspection Date <br />rp�1 Time In <br />1 'el_ SWn `l0' s (.o n� r odes <br />Tire Count (Whole/PTE) <br />O <br />GPS Latitude <br />0 <br />Inspector <br />0 1 (fin E5C'06 <br />d�05 <br />/� O AM0 <br />0 <br />1D <br />Time Out <br />0 PM <br />' <br />/� O AM0 <br />0 <br />Q AM <br />l.! 0 PM <br />0 PM <br />Operational Status <br />! Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />• Active <br />1 Q Passenger <br />® Generator <br />Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />A Indoor <br />Q Inactive <br />® Truck <br />Longitude - Q Planned ® OTR Q End -Use Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <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 A Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 114 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q Q 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Q 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q Q 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Q 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />1010 Other: § <br />Commentsim CIAIOMA _NLA „� <br />�0 V-LO�� rJ�15 yr GJ' CA5 Tj LO(IC, i)- - <br />� <br />u 1 a n <br />U Dismantler <br />Q Tire Derived Fuel <br />Tr" kf 4l r, i P <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 />Inspection Form Included: Q � <br />Comments Included: Q <br />B sines. R p's Signature - - Phone Number Insp�'�Signature hone Number <br />.. - - _ <br />�r, 62081 <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X "� �/' E A L � <br />■ White Copy: CIWMB Yellow Copy: Operator Pinkopy: ■ <br />