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Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> State of California T 1 <br /> 04104) <br /> California Integrated Was eC1WMI3 181eManagement Board Survey Form - Page 1 + +- 1143604 <br /> Part A- Survey___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 7 -7 -7 C Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local -C If Referral,choose referral type(Fill one) <br /> Identifier: �� ( Q / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> Physical Address 39 <br /> / <br /> (,., (� Inspection Date l 1 0 <br /> Time In Time Out <br /> Business Rep i Title 1 •AM Q AM <br /> O PM � p� � � 0 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 0 Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive S 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 FMQFORCEMENT STATUS <br /> V 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 <br /> 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 <br /> ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: 4nc <br /> CI6�3 <br /> Bu mess Reps gnature Phone Number t5 re Phone Number <br /> INSTRUCTIONS ON BACK Correct:6 incorrect: + Y?-1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy:L ® 0 <br />