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inspection Report Number <br /> Wa:;teaTire Su :y & Inspection Report <br /> aaaState of Californi <br /> CIWMB 04104) <br /> j/� <br /> California Int grat d,81 Was eeManagement Board Survey Form - Page 1 1 4 - 4 0 1 0 5 1 3 <br /> Part A- Survey BLUE_OR BLACK INK PEN <br /> Inspection Details <br /> 7 ^ Inspection Type (Fill one) <br /> St Suffix: iJ r ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t' `/.. t ���.+t a t t. �' /l, ` t t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name u Inspected By Inspector <br /> i <br /> Physical �ddress <br /> Street <br /> Inspection Date <br /> t, Time In_ =O <br /> _ Time Out <br /> City it State ZIP Cod" _ <br /> ------------- <br /> Business Rep Title AM 0 AM <br /> I f: <br /> O PM O PM <br /> Operational Status Tire Type T Business Role Storage Type <br /> Tire Count (Whole/PTE <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude I 0 Hauler Ilk Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> I- - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ', A :HAULING AND MANIFEST REQUIREMENTS <br /> -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date IT / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments u f f <br /> �t31t{��,.� A ; _r �(�-�l ! �iil Cj�i.' f�C,I �l) Y'Ylf� ' L' ?�F> < �(� 17 1(f �� �.���<✓1 <br /> l!���(' ✓�hf ;t) <br /> `. �I �L �I('+,��(ff. (1)lay I I��=/ � oo�-�rf ? �,-.Il,le 't/1 20D(P - 07 L <br /> _ - <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,�, ',/ E X A MIPILIE1 1112 3' 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />