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■ ess Waste Tire SUI y & Inspection Report nspection Report Number <br /> 6! <br /> Slate of California <br /> B 04/04) <br /> I 1 1140886 <br /> California Ine gr ed,Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 0y 41 J I Inspection Type (Fill one) <br /> Site Suffix: _�T/ f) Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: vh -6Q CHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected B <br /> / p y Inspector <br /> Physical AddressVZl / �� i l An4OW& <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM / (9 AM <br /> QPM I ! � Q QPM <br /> Ckzzy�L Coon - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �— ®Active Q Passenger ®Generator if Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <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 1 <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> 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 / 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 EXT) <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/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 1 Q Other: § <br /> Comments <br /> Inspection Form Included: Q, <br /> Comments Included: /�� <br /> Business Rep's nature one Number nspectAiSSignaZtutre:r <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A 11 2 3 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy: E <br />