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lCgtB Inspection Report Number <br /> Waste Tire Saey & Inspection Repor'. <br /> See B California I 1 - 1140899 <br /> California Int Brat Walte eeManagement Board Survey Form - Page 1 <br /> Part A- Survey - _ _ _ -__ - _ _ BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 3 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� J ,t w, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Na !�` <br /> Inspected By Inspector <br /> 13;11 Pa,y-gs <br /> Physical Address 0 <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title / 5- 0 AM ` S_ 0 AM <br /> 0 PM / 0 PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> r <br /> Tire Count (Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (o <br /> ®Active 0 Passenger 0 Generator Q Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 9 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ..-. ...- _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- -- -- - ----- ---- ----- -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 j 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date FTI / M / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 0 : 0 Other: § <br /> Comments-- <br /> f�/Gf C <br /> Inspection Form Included: 0 <br /> Comments Included: - -- _ -zacr --- - - ----- <br /> ®;Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - T r"-` 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect. E„X /t L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: ■ <br />