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Waste Tire Su, y & Inspection Report Inspection Report Number ■ <br /> =„a State B California I 1w 04104) — 1127480 <br /> California Int greC,We d 181 WaseeManagement Board Survey Form - Page 1 <br /> Part A- Survey --_-_ - BLUE OR-BLACK INK PEN <br /> 'Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5 ( 1 Q l e Routine Q Re inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: SaY 1 Scctqu�yl tA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> .�, Inspected By Inspector <br /> Ph&cal drams 3 9 ! <br /> _ Inspection Date <br /> Time In Time Out <br /> Business Rep Title 7 O AM Q AM <br /> '2 ®PM O PM <br /> K Pads <br /> - ---- - - -- - - ---- --- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> II*Active Q Passenger ®Generator 0 Outdoor <br /> GPS Latitude Q Closed Q Altered Q Hauler Q Indoor i <br /> 0 Q Inactive ® 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 ENFORCEMENT STATUS <br /> [V 1 A HAULING AND MANIFEST REQUIREMENTS j <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 i Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q I 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 DCT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <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 In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> V <br /> vY <br /> <= /:�cr <br /> ,Inspection Form Included: Q C, <br /> 7-3 <br /> Comments Included: 240Z?h, <br /> 1 d' c' - <br /> Qp S Filre - Phone Number - e r S'_nature Phone Number <br /> INSTRUCTIONS ON BACK Corre . In rrect: t _ V_ )( 62081 <br /> ■ White Copy: IWMB Yellow Copy:Operator Pink Copy:LEA <br />