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. . . .x, .T: . 1. . . _ . 11 . _ . J. ­ <br /> Waste Tire Su. y & Inspection Report nspection Report Number <br /> - State of California <br /> CIWMB 04/04) <br /> California Int gr ed'81 Was eeManagement Board Survey Form - Page 1 { f V - 10 1_ 4_ 7 4 A <br /> Part A- e= BLUE OR BLACK INK PEN <br /> Business Profile ' nspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: 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 N me <br /> Inspected B <br /> P y Inspector <br /> Physical Address r(� <br /> Street <br /> Inspection Date <br /> `((yy <br /> C h State ZIP ode Time In Time Out <br /> Business Rep Title O AM AM <br /> 0PM ' � 0P <br /> II i <br /> Operational Statustire Type Business Role Storage Type <br /> Tire Count (WhoIe1PTEf7r7""""""""7T (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 /> Latitude O (b Closed Altered <br /> GP$ m • � 0 Hauler OIndoor <br /> O 1 0 inactive Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that ap`, <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> OO m m m <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § -- - --- <br /> Comments L <br /> r��,Tln=�c, - <br /> ��-�1�T <br /> _ - <br /> Inspection Form Included: 0 <br /> Comments Included . "aIIIIIIIIIIIiiBusine_ss Rep's Signature Phone Number --sins9gotor's Signature,,, Rhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � � E (I A tMl R 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> —---•�,.:�-----—__ - -- --- -a—rte-,---- -r-_-'--__._ --' <br />