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Waste Tire Afey & Ins ection Re Inspection Report Number <br /> t•-. p p <br /> III State of California T 1 <br /> ew 04104) <br /> California Integral d,81 WasCIWMB te Management Board Survey Form - Page 1 I i 1140926 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Q _ Q Inspection Type (Fill one) <br /> Site Suffix: I J S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S)6m - 1 Q 41 Q an —Ch, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V V w V I <br /> J Inspected By Inspector <br /> I N Tr f) <br /> O�of I c ALJ, <br /> Physical Address 30 n to <br /> lel <br /> (A <br /> ^��O� Inspection Date <br /> 'J.�1 yl Time In Time Out <br /> Business Rep Title O AM OAM <br /> �PM-_ � � A PM <br /> Ton (,Ujfa �N�n� - -- <br /> ----- - - - -- --- - --- - ---'--V�' - Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n (Fill one only) I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l0 Active * Passenger Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 ® Other 7ow"Pj <br /> (O qnj <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS r . <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 DateM / M / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (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/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 mioatll;an <br /> P—c4c frngiek o A <br /> Inspection Form Included: <br /> Comments Included �I f —� " 7 — cAJ-�tlY.�31-1-1�---- <br /> u Hess Rep's Signature Phone Number Ins' or's Siinature Phone Number <br /> - --- <br /> - T 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect � E }C A, M P L E � 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LEA <br /> f <br />