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Waste Tire Surty & Inspection Report Inspection Report Number ■ <br /> State of CaliforniaIQ CIWMBy - <br /> alifornia gratedf81 WasteeManagementBoard Survey Form - Page 1 ? E , ;_ ' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection betails <br /> -- - -- <br />} TPID- I _ Inspection Type (Fill one) <br /> Site Suffix: '? � �1�� lLIj— Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: YT 4T- �� �. tl , f ti �w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U - <br /> Inspected By Inspector <br /> r ; <br /> Physical Address ET <br /> - C,% <br /> _ fit <br /> (6,; A�A ' — <br /> street: , � <br /> Inspection Date <br /> City State . ZIP Code Time In Time Out <br /> Business Rep Title Q AM �� Q AM <br /> LLi - 1-1-1' 0PMEE] " QPM <br /> — i I ----------- <br /> Operational Status Tire Type <br /> i Business Role Storage Type <br /> (Fill one only) (Fill all that appIY)Tire Count (Whole/PTE) (Fill all that apply) (Fill all that apply) <br /> y) <br /> �m <br /> gg Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude O ) Closed Q Altered <br /> GPST� Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> 1 Longitude Q <br /> . Q Planned Q OTR End-Use Container <br /> - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Date M / M / F7 <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 EXT) <br /> Q Q 14 CCR 18459.3-Retention of Comprehensive Trip Logs for 3 years - - <br /> 1 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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: <br /> Comments - I <br /> l ta, <br /> Inspection Form Included: Q' <br /> Comments Included: 0:: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />