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«:. Waste Tire NOR & Inspection Rep*%Spection Report Number <br /> � <br /> �� State of California I 1 - 1127921 <br /> Calif InCIWMed,81(New 04104)Waste Management 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: -inspection& Routine Q ReQ Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ` �C{,>f� �e�cN1 O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Addressrn��l� <br /> Inspection Date <br /> CA �5ai�+6 Time In Time Out l <br /> Business Rep Title l AM ®AM <br /> 1 O PM ' © O PM <br /> NO Cu—- �'- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> ®Active Q Passenger ®Generator Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O 0 Inactive 40Truck <br /> Longitude - 0 Planned Q OTR 0 End-Use ® Container <br /> Business Type (Fill all that apply) 1 _ <br /> O 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 O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q in Compliance - No Violations <br /> Other: § - - - -_ <br /> Comments <br /> h <br /> Lama?to,nhs -a _ <br /> Inspection Form Included: Q <br /> Comments Included: -AcG/ 1--mow��s - � - -- - -- - <br /> ®' - <br /> Business Rep's Signature Phone Number has ct is tura_ Phone Number <br /> - - - - — 1 ,., 62081 <br /> INSTRUCTIONS ON BACK Correct S Incorrect. X 1 X h dtr'rl <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: E ® ■ <br />