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08234040301 <br />Waste Tire Survey & Inspection Report Inspection Report Number <br />ar State f <br />ClWM181(emte SurVe Form - Pa e 1 I1 - 1088151 <br />Callfomla IntagrateE Waste Management Board <br />Part A - q.-. . RI IIF np RI ACK INK PI=N <br />Business Profile <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Inspection Details <br />Q <br />TPID -I <br />Site Suffix: <br />I <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 -Responsible Entities Complying with Manifesting Requirements <br />Q <br />- <br />tJ <br />/ <br />Q <br />Inspection Type (Fill one) <br />Q <br />Q <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 />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0101 <br />0 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 />Local <br />Identifier: <br />/ <br />TO,q�'n/ CAuN icy <br />V <br />Business or Facility Name <br />eo-sT13 <br />Inspected By Inspector <br />g - / <br />Physical Address <br />o i <br />Zq&o s. Owy Q9 <br />I <br />StreetC l'952J-3,m <br />Inspection Date <br />� c� OG�L'�C7Y) <br />G,4. <br />Time In _Time <br />O AM <br />t� <br />Out O AM <br />T <br />I l <br />City State ZIP Code <br />Business Rep Title <br />' 1 0 PM <br />' ' _ ; O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />,(Fill all that apply) <br />0 Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />40 Generator <br />Q Hauler <br />Q Outdoor <br />Q Indoor <br />— _ O <br />d <br />GPS Latitue <br />0 <br />Q Inactive <br />0 Trude <br />Longitude- <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q.Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder .Other LGl1G/�_M�in/ttF+t rctie✓J <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <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 />Q <br />14 CCR § 18459 -Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <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 />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0101 <br />Other: § <br />Comments <br />nspection Form Included: Q <br />Comments Included: Q - <br />s' ess Rep's i re Ph a Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: <br />White Copy. CIWMB Yellow Copy Operator <br />A,6 <br />IEIXIAIMIPILIEI 1112131 <br />62081 <br />Pink Copy. LEA ® . ■ <br />