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Waste Tire SI y & Inspection Repot nspection Report Number, ■ <br /> W U, State of Californiao CIWMB 181(Nw 04104) <br /> f t a <br /> California Integrated Was eeManagement Board Survey Form - Page 1 3 a . - f - - <br /> Part A- Suryey BLUE OR BLACK INK PE.N <br /> ss 1 <br /> SustneProfile — --�Inspection betails _ - <br /> TPID-� Inspection Type (Fill one) <br /> Site Suffix: L <br /> t'_ _ 0 Routine 9) Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �. � E` �! r ,I { � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Othe <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address _ <br /> street <br /> >f _ Inspection Date <br /> rryi State TIP Code Time In Time Out _ <br /> Business Rep Title AM <br /> M <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r i <br /> Active 0Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPSLatitude 0 0 Hauler 0 Indoor <br /> Inactive 0 Truck I <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 !i <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> . 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f 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 <br /> Inspection Form Included: 0 I <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ,_N,� , �, I_ � L M, <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />