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® = Waste Tire Abay & Inspection Repco Inspection Report Number <br /> State California <br /> B 04/04) <br /> 11 - 1141344 <br /> 4, California lnegrat dfWaseeManagementBoard Survey Form - Page 1 <br /> Part-A--Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' �J _ O Inspection Type (Fill one) <br /> Site Suffix: 3 b �- ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` '�� �� If Referral,choose referral type(Fill one) <br /> Identifier: I ► l (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Ins ected B <br /> p Y Inspector <br /> 6-m <br /> Physical IA reS J u P _ <br /> Inspection Date O �9 <br /> ►`�a,� I�Cc� Cry Q�S37 c <br /> Time In Time Out <br /> Business Rep /O AM / Q AM <br /> f D 0PM— 1 OO ® PM <br /> - - - ---- <br /> Operational 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 /> f ® Active Q Passenger go Generator ® Outdoor <br /> o GPS Latitude 0 Q Closed Q Altered <br /> 2j Q Hauler � Q Indoor <br /> D Q Inactive i ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other Ila Os�+ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA I HAULING AND MANIFEST REQUIREMENTS <br /> ® Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateF/ <br /> Q Q 14 CCR§18459.1 Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> ® Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 1 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 014 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q in Compliance - No Violations <br /> Q Q Other: § <br /> Comments L� <br /> Inspection Form Included:& / / a'-_' &n, <br /> Comments Included: ® �� - — —��)Busi ess Reps Signature Phone Number ture Phone Number <br /> INSTRUCTIONS ON BACKX I 62081 <br /> � <br /> White Cop':CIW Yellow Copy:Operator Pink Copy:LEA <br />