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Waste Tire SL y & Inspection Report nspection Report Number <br />State of California 1 - 1140892 <br />Callfomia Int gr ed,81 Wast eManagement Board Survey Form - Page 1 <br />Part A - Survey _ __ _ _ BLUE OR N <br />_BLACK INK PEN__ <br />Bne <br />usiss Profile 'Inspection D_etails <br />TPID - <br />Site Suffix:/ 3 cl <br />Local <br />Identifier: <br />Business or Facility Name <br />Physical Address <br />7 <br />Business Rep <br />I <br />Tire Count (Whale/PTE) <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />® New Tire Dealer <br />0 Auto Repair <br />® Used Tire Dealer <br />0 Auto Body <br />0 Service Station <br />0 Hauler <br />r Inspection Type (Fill one) <br />1 ®Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />Aw <br />eA <br />Title <br />Inspection Date 1 ,2 <br />Time In <br />I I <br />0 AM <br />®PM <br />Operational Status Tire Type <br />Z (Fill one only) (Fill all that apply) <br />® Active ® Passenger <br />O 0 Closed 0 Altered <br />3 i / <br />/ 0 <br />Time Out <br />0 Car Dealer <br />' <br />_ 0 AM <br />S <br />0 Agriculture <br />0 PM <br />Business Role <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />® Generator <br />0 Outdoor <br />p 0 Inactive 0 Truck 0 Hauler 0 Indoor <br />0 Planned 0 OTR 0 End -Use 0 Container <br />0 Trucking Fleet <br />0 Government <br />0 Retreader <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 Agriculture <br />0 Shredder <br />0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V'- A <br />—... <br />HAULING AND MANIFEST REQUIREMENTS <br />- <br />0 <br />0 <br />---- __. _.._......... <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § <br />Comments 1/11) i <br />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date m /m/m <br />'L <br />(Required for NOV or EXT) <br />0 Referred/ CIWMB Enforcement <br />In Compliance - No Violations <br />'inspection Form Included: U <br />Comments Included: ® n <br />Business - ep's Signature PYone Number Inspector's Signature - _ Phone Number, <br />_. 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: X V I X A (- f 2 3 <br />White Copy CIWMB Yellow Copy: Operator Pink Co : L <br />