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Waste Tire Su&y & Inspection Report Inspection Report Number <br /> U <br /> State of CaliforniaDCalifoiaIntegrated CWMB'Waste 81 eManagement Board Survey Form — Page 1 I 1 d `4 4 <br /> 71 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile i4kmmiikig6WNi.lnspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: E_ , , "J (`: "\j z - O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> Physical Address 1 �� <br /> Street <br /> Inspection Date J C1 <br /> I P/—,'/ I TS-r 6L CA <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title EF <br /> 0 AM OAM <br /> O PM ' �.- O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE A :A2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> „ C) Active Q Passenger Q Generator O Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude f= Q Hauler O Indoor <br /> _71 -1. H I 1O Q Inactive � Truck I <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler (D Agriculture Q Shredder Q 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 /> Notice Of Violation Q 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 IT / FF / 7 <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 O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: 0 — - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X F- A, M P I L i 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />