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Waste Tire Survey & Inspection Repoli i Inspection Report Number ■ <br /> ��v== State B California I - 1140952 <br /> California Int grat dWe <br /> Waste Manw 04/04)agement Survey Form - Page 1 <br /> A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> TPID- C p r� Inspection Type (Fill one) <br /> Site Suffix: J l / (8 Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: Sego 100IL 6, ( n, r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> r <br /> K;e_ID► &("II ;(_ <br /> Physical Address <br /> n <br /> %0o A <br /> C.L Inspection Date Z <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> -- ---- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) )2� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Q Active Q Passenger Q Generator Q Outdoor <br /> PS Latitude DD S Closed Q Altered / �Gj Q Haule Q IndoNl <br /> 4 <br /> Q Inactive QTrucNl <br /> Longitude - <br /> g Q Planned Q OTR Q End-Use Q Container <br /> M.'siness Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> U 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 <br /> 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 <br /> 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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> - <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> IS In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> I <br /> inspection Form Included: Q <br /> Comments Included: 40,- - — Ine <br /> Business Rep's Signature Phone Number Number <br /> ---- - - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X 1 E X A MP: 112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />