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=ooWasteaTire Sugey & Inspection Repor <br />State of Californiw 04104) <br />Calif Integrated CWMB 'Wast 81 eManagement Board Survey Form - Page 1 <br />Part A • Survey <br />Business Profile Inspection Details <br />TPID - IInspection Type (Fill one) <br />, I <br />Site Suffix: I / I ! `i f c' Fil - C) I I <br />Local <br />Identifier:-'/ <br />Business or Facility Name <br />r <br />Inspection Report Number <br />i 7.1010004 <br />BLUE OR BLACK INK PEN <br />0 Routine 0 Re -inspection 0 Referral Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />Physical Address <br />Inspection Date I ✓ / ) �� / l? r/ <br />State Zlp Code Time In Time Out <br />Business Rep Title m 0 PM ' m C <br />Operational Status Tire Type Business Role orage T <br />(Fill one only) (Fill all that apply)' (Fill all that apply) all that <br />Tire Count (Whole/PT <br />0 Active 0 Passenger 0 Generator utdor <br />0 0 Closed 0 Altered <br />GPS Latitude �� 0 Hauler doo4 <br />O 0 Inactive 0 Truck <br />Longitude — 0 Planned 0 OTR 0 End -Use Contail <br />all that a I r .. <br />Pp Y)� , <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 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 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: § <br />Comments IUI <br />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 / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: U' <br />i; Comments Included: 0 <br />f Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />,,�, <br />X / f I� 62081 <br />INSTRUCTIONS ON BACK Correct:* Incorrect: ��i � � �„ F LK aN <br />White Copy CIWMB Yellow Copy Operator Pink Copy: LEA <br />