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Waste Tire Survey & Inspection Reps. ,L Inspection Report Number ■ <br /> State CIWMB California I 1w 04104) - 114 3 8 2 0 <br /> Californialne grat dWase181 eManagementBoard 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 /> � J7O <br /> Site Suffix: / J ' e Routine Q Re-inspection Q Referral Q Observation <br /> LocalI (M�4 If Referral,choose referral type(Fill one) <br /> Identifier: Q( (,,t (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> --_ - -- - - <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 9 <br /> Inspection Date 0 u Q <br /> So"`� V� V Time In Time Out <br /> BusinessRep <br /> �n 1 Title ( 1 O AM U O AM <br /> O O A PM ® PM- <br /> - - - ---- - -- - - - , -------- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger • Generator 40 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 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 /> i 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 <br /> M / m <br /> 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 19 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1 <br /> e-`, `_ FG,C t �1 C� 1 U GLS I.r 1� � leC- <br /> R(b�Inspection Form Included:Comments Include "I- <br /> Inspec is Signature e`s Si natu Phone Number � hone�Number <br /> umber <br /> l0 <br /> INSTRUCTIONS ON BACK Correct: Incorrect X i\;�p E X p L µ 1 : 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pin Lo <br /> p ■ <br />