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Waste Tire Sup ,y & Inspection Report ..Ispection Report Number <br /> Slate oC,WMBf California T 1 <br /> 04104) <br /> California lne grat d,81 WaseeManagementBoard Survey Form - Page 1 I y 1140843 <br /> Part A- Survey — BLUE OR BLACK INK PEN <br /> i- <br /> Business Profile Inspection Details <br /> TPID- Inspection_ O I Inspection Type (Fill one) <br /> Site Suffix: (O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cr Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - - - - <br /> IBusiness or Facility Name - <br /> Inspected By Inspector <br /> Physical dress / le"C, <br /> I y F F Ll )rrzrn ham- 1,"k A - - - - <br /> Inspection Date <br /> Site CA q�x1s u l 1 0 <br /> Time In Time Out <br /> Business Rep TitleO AM f r� Q AM <br /> f Ll S 0 PM 0 ® PM <br /> - <br /> - S - 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 /> `� ' 9 Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Planned 1 Q OTR i 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 /> I <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 j <br /> — .... - <br /> V I A HAULING AND MANIFEST REQUIREMENTS 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 <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 o{EX7) <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 <br /> In Compliance - No Violations <br /> Q O (Other: <br /> Comments <br /> Inspection Form Included: QI <br /> Comments Included: <br /> -_ <br /> s <br /> Busi Sig ature Phone Number pector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr`e t" -1`rtcortect� " LJ r 62081 <br /> ( <br /> l� L� j <br /> ^! <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />