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Waste Tire Su�y & Inspection Report ' spection Report Number <br /> State of CaliforniaCIWMI3 04104) I ri rj i <br /> California Int grat d,81 Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Bustnefa '' — <br /> nsp <br /> i'lectl, <br /> �.. _ _ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t�a j t_ t.. Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local i f If Referral,choose referral type(Fill one) <br /> Identifier: ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> i <br /> Business or Facility Name r Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date LJI -ail L <br /> Time In Time Out <br /> Cify � State ZIP Cede T __._.., .�. <br /> Business Rep Title Q AM _ O AM <br /> PM <br /> 0 PM <br /> - - Operational Status I Business Role Storage Type i <br /> The Count(Whole/PTE) (Fill one only) (FII" (Fill all that apply) (Fill all that apply) <br /> Active Generator Outdoor <br /> 0 <br /> Indoor C 0 Hauler losed AI�� <br /> LatitudeJ­"I <br /> GP$ 0__-J 0 Inactive 0 Truck <br /> - O <br /> Longitude - 0 Planned 0 OTR End-Use Container <br /> Business Type (Fill all that apply), > s <br /> 0 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 I ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 !ii 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 _- -- - -- ----- <br /> � 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 In Compliance No Violations <br /> -- -- - <br /> 0 0 Other: § <br /> Comments <br /> 1, — Ifs <br /> it _ <br /> 8 s <br /> Inspection Form Included: 0 <br /> Comments included:0: t_ <br /> Business Rep's Signature Phone Number Inspector's Signature y Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: . P L 1. 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />