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=_ Waste Tire SPrvey & Inspection Report Inspection Report Number <br /> ,I State of California a y a �`a <br /> Calif Integrated WasNeManagementBoard Surveyew 04104 Form `� Page 1 1 a� � 0 7 3 3 0 <br /> BLUE OR BLACK INK PEN <br /> Part A-Surve <br /> Business Profile Inspection Details <br /> TPID- C� ® Inspection Type (Fill one) <br /> Site Suffix: \ 3 p ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �n �6G1��►� (0 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical A dress Escbb <br /> � <br /> Inspection Date 5O �� <br /> Time In Time Out <br /> Business Rep Title / 1 5 O AM O AM <br /> C <br /> 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 /> Tire Count(Whole/PTE) <br /> O Active Q Passenger &Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ff 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 ®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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS--------.-,, <br /> V A HAULING AND MANIFEST REQUIREMENTS Q 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 Date m / m / m <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 /> - -- - - --- <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 14 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 ® In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments rA k s��nc�jU�-,0/N <br /> 0 OV <br /> w r <br /> Ses" CPmYran 3 For(Y-\ <br /> Inspection Form Included: Q <br /> Comments Included: —` <br /> Business Rep's Signature Phone Number Inspec 's Signature one Number <br /> — -- ---- __ 62081 <br /> INSTRUCTIONS ON BACK [Correct.0 Incorrect X V, � � � IJiP l EI <br /> ® <br /> White Copy:C:CI <br /> WMB Yellow Copy:Operator Pink Copy:LEA <br />