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Waste Tire SL ey & Inspection Repor. Inspection Report Number <br />State oCJWBf California t1 <br />04104) <br />California Int gree dfWas eeManagement Board Survey Form - Page 1 I Ili <br />Part A - Surve BLUE OR BLACK INK PEN <br />Business Prd _ -- nspection Details - <br />---- - <br />Business <br />- - / Inspection Type (Fill one) <br />Site Suffix: 1 / S I (� I I I f l� 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local i If Referral, choose referral type (Fill one) <br />Identifier: J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name <br />f Inspected By Inspector <br />Physical Address <br />Street <br />1)2- <br />;3ity State ZIP Code <br />Business Rep Title <br />Tire Count (Whole/PTE) ® 1 <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Service Station 0 Hauler 0 Agriculture <br />0 <br />Inspection Date <br />Time In <br />0 AM <br />Time Out <br />0 AM <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 P <br />-�- <br />PRC § 42956 - Registration/Decal in Vehicle <br />0PM <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 />I) Active <br />0 Passenger <br />0 Generator <br />0 Outdoor <br />0 Closed <br />0 Inactive <br />0 Altered <br />0 Truck <br />0 Hauler <br />0 Indoor <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />0 Government <br />0 Collection <br />0 Shredder <br />0 Retreader <br />0 Crumb Rubber <br />Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments <br />0 Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: 0 <br />Comments Included: 0- - �_-.. ---- <br />Business Rep's Signature Phone Number Inspector's Signature _ Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: XJ�,\/ E x I A m P, L, L; _T1 I -fl-31 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />