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P �� Waste Tire SL ey & Inspection Repor. Inspection Report Number <br /> IIIHI State of California T 1 <br /> California ICIWMB 04/0 <br /> nt grat df81 Was eeManagement Board Survey Form - Page 1 I 1 1141270 <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: _ - 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U " Inspected By Inspector <br /> ,11'A1.i"C;\.l S �Yl f <br /> Physical Address f�[ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title �J 0 AM Tv0 AM <br /> cl��� ��� � � �1G �U ��/ 0,PM I ' �..� � ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger I&Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 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 O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> . <br /> V i 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 O 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 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 /> O 0 Other: § <br /> Comments f / <br /> The &A10 OA-4' - <br /> 1 / <br /> Inspection Form Included: Q i <br /> Comments Included: 0 sine257��2 t7 ` <br /> uss Rep's Ignature Phone Number inslAltor's/Silifnature Phone Number <br /> -- - - - -- - - 62081 <br /> iNSTRUC ONS ON BACK Correct Incorrect: X I XC I Alli P 2 3 <br /> �A/hire Copy:C14✓iv1t3 'yellow Coey:Operator Pink Copy:LFA <br />