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LCPP- <br /> Waste Tire, ey & inspection Rei �' Inspection Report Numb r <br /> .f <br /> State of California <br /> CIWMB 8ast(New <br /> Manag) Survey Form - Page 1 I 1 1088329 <br /> California Integrated Waste Management Board Y `� <br /> PartA- Survey __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � 5 L U � � Q � Inspection Type (Fill one) <br /> Site Suffix: Q Routine ® Re-inspection Q Referral Q Observation <br /> Local ��� lJ If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physics AddrLssV1 �� <br /> \ p Inspection Date <br /> Time In Time Out <br /> Business Rep Title , ? 3 O O AM �J Q AM <br /> 7 cf6a►l� w l�cam� J ®PM C ® 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 /> V ® Active ® Passenger ®Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End Use Q Container <br /> Business 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 /> ® 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 /> VA ;HAULING AND MANIFEST REQUIREMENTS rt.. Q Notice,Of Violation Q Extension <br /> Q 0 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 /> 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 /> — - --- <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q <br /> - --- -- --- <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 Vi ti ns. <br /> Q Q Other: § --- <br /> Comments <br /> IInspection Form Included: Q p ¢ �j/ <br /> Comments Included: / o �� ��G o 72 <br /> usiness Rep's Signa Phone Number In or's i nature Phone Number <br /> INSTRUCTIONS ON BACK 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />