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Waste Tire fty & Inspection Repor Inspection Report Number ■ <br />State of California T 1 <br />04/04) <br />California Ine gran df81 Was eeManagement Board Survey Form - Page 1 + i 1141189 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: , 3 a / I J� - I 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local \ If Referral, choose referral type (Fill one) <br />Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Agar � � 13 <br />�� l J F<1:106 <br />I � <br />Street ! Eou Inspection Date i <br />,late _' _._...._.._ _._._..._._._. <br />� p Code I ..... <br />Time In Time Out <br />Business Rep Title O AM Q AM <br />— !.. QPM _.f_ _. O PM <br />(i�ul c , ?��si isle nt rrrn,t I I ----a' <br />...... _ .... _.. _ .. _. .... .. ........... �.l_._. Operational Status Tire Type Business Role Storage Type <br />The COUnt (Wh01elPTE) (Fill one only) (Fill all that apply) , (Fill all that apply) (Fill all that apply) <br />0 Active 0 Passenger 0 Generator 0 Outdoor <br />C 0 Closed 0 Altered <br />GPS Latitude 0 Hauler 0 Indoor <br />0 0 Inactive 0 Truck <br />Longitude — 0 Planned 0 OTR 0 End -Use 0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer <br />0 Auto Repair <br />0 Trucking Fleet <br />0 Government <br />0 Retreader <br />0 Used Tire Dealer <br />0 Auto Body <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 Service Station <br />0 Hauler <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 HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <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 />0 <br />0 <br />Other: § <br />Comments <br />0 Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred I CIWMB Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: 0 <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspector's Signature <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: X ; L X < A M ? l- [ ? <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />® ■ <br />