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Waste Tire SA*y & Inspection Repodoinspection Report Number <br /> State of California m 1 T 1 1141243 <br /> California Integrated fWast 81 eManagement Board Survey Form 1 1 - Page 1 �.._. 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 1 € Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �'�) � (Z � \n ���1., <br /> U Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address �7C) t <br /> L. __._. __...1..._.__ ........_.___.__._.__.._.__...._....___...._._._.._......._..............__.................................1 __ 1 <br /> Sib eet <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM 3 `� O AM <br /> 1 <br /> o� <br /> L U QPM j QPM <br /> LOperational 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 /> 0 Active 0 Passenger 0 Generator O Outdoor <br /> D Q Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> Q Inactive 0 Truck <br /> Longitude — O Planned Q OTR O End-Use Q_Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> r Q Used Tire Dealer 0 Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station Q Hauler 0 Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 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 /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X (= Xti A M,P, E 1 : 2 ,3, 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />