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Waste Tire Survt.,, & Inspection Report .-,action Report Number <br /> i= State California I 1 1143767 <br /> o�lne grat B dWase181 eManagement Board <br /> w 04104) Survey Form - Page 1 <br /> >urvey_-_-- BLUE OR BLACK INK PEN <br /> Profile Inspection Details <br /> - � I Inspection Type (Fill one) <br /> lx' • Routine Q Re-inspection Q Referral Q Observation <br /> �\ If Referral,choose referral type(Fill one) <br /> !r: �Un v0 �ln �' `Y"\ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ,s or Facility Name J <br /> Inspected By Inspector <br /> ,671C�1�S <br /> al Address <br /> c�2'�O <br /> Inspection Date a o(„ 1 <br /> n � g52�(o �Y l v <br /> Time In Time Out <br /> ness Rep Title t r� 41 AM [ AM <br /> 1 V O PM J O PM <br /> - - - - - Operational Status Tire Type Business Role Storage Type <br /> 'ire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger Generator e Outdoor <br /> O Q Closed Q Altered <br /> 3PS Latitude Q Hauler Q Indoor <br /> O Q Inactive ID Truck Longitude - ® OTR Q End Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 J ENFORCEMENT 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 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 f 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> utz ��� � Ir _an` ;�-- mac n_� o 1� r w s_�Q c�;_ <br /> U 7AS q,-�j <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspe _is ignature _Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: X tJJEXJA#JPJ�je�-�112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink o y: ® ■ <br />