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TPID - <br />Site Suffix: _I._ <br />Local <br />Identifier: <br />Business_ or Facility Name <br />Physical Address <br />Street <br />City State ZIP Code <br />Business Rep Title <br />�.aa+aw�_,.< <br />i <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />92 <br />Inspection Type (Fill one) <br />Q Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By <br />Inspector <br />Inspection <br />Date 101° I <br />f <br />I L`-' <br />IIITime <br />Time In <br />-��'�--O <br />AM <br />Out <br />0 AM <br />O PM <br />0 P <br />Operational Status Tire Type <br />r Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Passenger <br />Q Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q Government <br />Q Collection <br />Q Shredder <br />Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Crumb Rubber <br />Q Other <br />ENFORCEMENT STATUS <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <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 <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 <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 />Q Q Other: § <br />Comments <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m /-m <br />(Required for NOV or EXT) <br />Q Referred/ CIWMB Enforcement <br />Q In Compliance - No Violations <br />Inspection Form Included: Q <br />Comments Included: Q _ <br />Business Rep's Signature Phone Number Inspector's Signature _ Phone Number <br />- - -- — <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X EF 7XA: [p 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ■ <br />