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$� <br /> Waste Tire Sufty & Inspection Report nspection Report Number <br /> State T 1 <br /> of California <br /> California Integral dfWasCWB (te Management Board Survey Form -_Page 1 +. y 1140720 <br /> Part A- Survey BLUE_ OR_ BLACK INK PEN <br /> [Business - <br /> iBusiness Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: o Sb If Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f,,, , , ;� O CHP O CIWMB 0 Complaint 0 Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - <br /> 19 3R <br /> Inspection Date O <br /> LSccc <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> r <br /> ' S ® PM O L 3 v ® PM <br /> Operational Status Tire Type Business Role-1 Storage Type <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply),I (Fill all that apply) I (Fill all that apply) <br /> 0 Active ® Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> C 0 Inactive ® Truck i I <br /> Longitude - 0 Planned ® OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> (® 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 /> i <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / <br /> m / F11 <br /> 0 0 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/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> (x�flnne� ov-- A&&.,!- <br /> k CS <br /> ✓�,o�cc `c -�f CV-Y' �r s Ccf n�irY`- <br /> Inspection Form Included: 01 <br /> Comments Included: <br /> O,Business Rep's Signal a Phone Number InSignature Phone Number <br /> _ - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X EVA L e 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: <br />