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09182.0402115 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CrWMCalifornia <br /> 013 <br /> Surve Form - Page 1 ! I 1 --_1108458 <br /> CIWMB 161 181((New 04!04) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID. 1 �/ ' I Inspection Type (Fill one) <br /> Site Suffix: J__i ® Routine Q Re-inspection Q Referral <br /> Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i Inspected By Inspector <br /> Physics Address <br /> 5trect Q Inspection Date i 6 <br /> Slat i;;,C u a Time In __ Time Out _ <br /> Business Rep Title I i I �� </ . AM 1 � I�i ®AM <br /> y� � 10 PM '_ l_ I� 1 QPM <br /> - ne - Operational Status .Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ,.0- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' ®Active • Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q.Dismantler Q Tire Derived Fuel <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 e Q Other <br /> — ——-- - - -- —--1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> Q Q 14 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 (Required for NOV or EXE <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 Q Referred I CIWMB Enforcement <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 ® In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> o. �.r4. �„� fz <br /> // <br /> t )C�_-5 JPO �= I�1/ O V�2_�� � J2t°�c�—t6Vl���'l/.LLM�/�J <br /> Inspection Form Included: Q <br /> Comments Included:Q <br /> Busine s Rep's SI tur Phone Number In e o s ign ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC C rect Incorrect: ( 1� X A M P L 1 2 3 <br /> White Co :CIW B Yellow Copy.Operator Pink Copy.LEA <br />