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Waste Tire Sulky & Inspection Reporto Inspection Report Number <br />=SII State of California 1 - €€.�� <br />California IntegratedCIWMB tWaste81 eManagementBoard Surw 04104)vey Form - Page 1 I ? ( 6 U <br />Part A - Surve BLUE OR BLACK INK PEN <br />nspection Details l <br />TPID - Q /l % / Inspection Type (Fill one) <br />Site Suffix: I /- / ` 1 ( Q Routine Q Re -inspection Q Referral Q Observation <br />Local r" — / If Referral, choose referral type (Fill one) <br />Identifier: is r�li t t , I , �, c l IT Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By <br />Physical Address j –FIT <br />Inspector <br />L-( r C r <br />i- i r i <br />-),z <br />I <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Street <br />�_- <br />s <br />^ <br />Q <br />Inspection Date <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />r <br />,L/ <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />City <br />Business Rep <br />Q <br />State <br />Title <br />ZIP Code <br />Time In <br />0 AM <br />Time Out <br />O AM <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q PM <br />O PM <br />Other: § _. <br />Comments `- <br />r � <br />i(l)� <br />Operational Status Tire Type <br />Business Role Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) (Fill all that apply) <br />(Fill all that apply) (Fill all that apply) <br />Q Active Q Passenger <br />Q Generator Q Outdoor <br />O <br />Q Closed Q Altered <br />I <br />GPS Latitude <br />m <br />• <br />Q Hauler Q Indoor <br />r <br />o <br />Q Inactive Q Truck <br />Longitude <br />– <br />F <br />Q Planned Q OTR <br />Q End -Use Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer <br />Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer <br />Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station <br />Q Hauler <br />Q Agriculture <br />Q Shredder (Z) Other I Oji / � f 4c 7. (41 <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § _. <br />Comments `- <br />r � <br />i(l)� <br />Inspection Form Included: Q! <br />Comments Included: Q - - -- <br />Business Rep's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X �, <br />White Copy: CIWMB Yellow Copy: Operator <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred I CIWMB Enforcement <br />Q in Compliance - No Violations <br />Inspector's Signature <br />Pink Copy: LEA <br />Phone Number <br />62081 <br />