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Waste Tire"y & Inspection Rep6-winspection Report Number <br /> State B CaliforniaC,WMI 1 w 04104) - 1141317 <br /> California lne grat d'Wase81 eManagementBoard Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- t /,� 0Inspection Type (Fill one) <br /> Site Suffix: "l O \ 0 Routine ®Re-inspection 0 Referral 0 Observation <br /> Local \ /� _ If Referral,choose referral type(Fill one) <br /> Identifier: �`yj (,@�LfV b Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �^ Inspected By Inspector <br /> J0.�'1UCk"s <br /> Physical Address <br /> Inspection Date "1 <br /> Time In l Time Out <br /> Business Rep Title l Q AM Q AM <br /> l ®PM a PM <br /> Operational Status Fire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t � � Q <br /> 0 Active i® Passenger &Generator ®'Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude O Hauler IWIndoor <br /> 0 Q Inactive Q Truck i <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair 0 Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder ®Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - - - <br /> V A j HAULING AND MANIFEST REQUIREMENTS violation 0Extension j <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires °fir <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. 'Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 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 <br /> Q 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 <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: O� <br /> Comments <br /> Sem men f - <br /> Inspection Form Included: 0 <br /> Comments Included: ® Business Re s Signature Phone Number Ins o g ature 'Z Z� p�io Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect X : ; 1E; AMP IT2� 62os1 <br /> -- --- <br /> White Copy:CiWY1B vP.iiGW Copy:Operator Pink Copy:LEA <br />