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Waste Tire Sfty & Inspection Repoi Inspection Report Number ■ <br /> ■ lit Stateof California <br /> CIWM04/04) <br /> California Integrated 181 <br /> e <br /> WaseManagementBoard Survey Form - Page 1 I 1 - 1143738 <br /> Part A- Survey . . - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O 1 Inspection Type (Fill one) <br /> Site Suffix: l•t l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r-` If Referral,choose referral type(Fill one) <br /> Identifier: s n J �/t C, CIO I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Coiddr(e-sosl��no�s�l�--1 iT C�-t _Physical 39 1 () j <br /> 'J <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM U O AM <br /> MM I <br /> a : 3 ePM ` ® PM <br /> - — - - ---- - -- - ---- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 40 Generator 0 Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q End-Use Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 ® Other <br /> 'r,� CP_4trc <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q1 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 Date In I / b M10 <br /> Q 40 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 DCT) <br /> ® 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 1 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 Q In Compliance - No Violations <br /> Q Q Other: § r' <br /> Comments 1� (A Ly) <br /> vo Yl n s Ir <br /> Inspection Form Included: ,Zsry�s�spec s Signat��`Comments Included: Bu Hess Rep's Sig lure Phone Numer Iure Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �/� + N�P j (� i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />