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gra; Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> 04/04) <br /> Califof4fia Int grat B tWas eeManagement Board Survey Form - Page 1 Il - 1140588 <br /> ' Part A-Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> 1- / - Inspection Type (Fill one) <br /> bice Suffix: , (� rj' L/ c) 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -, � CtLt,t,t� ��, , , �-u 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> n P y Inspector <br /> 1_i <br /> Physical Address <br /> Inspection Date ! 7 <br /> Time In Time Out <br /> Business Rep Title O AM ,�r1 Q AM <br /> ` I 0 PM v o ® PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> (� New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Govemment 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> sed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Statin, 0 Hauler 0 Agriculture 0 Shredder Other <br /> - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS D Notice Of Violation 0 Extension <br /> ._._._. <br /> O 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 /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date []:] / El / <br /> m <br /> 0 0 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> Q 0 Other: § <br /> Comments <br /> I tion Form Included: Q <br /> Comments Included: 1 � � `>� <br /> _ Business Rep's Si nature Phone Number/ spector's Signature Phone Number, <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X �/ � x is j p 1 3162081 <br /> White Copy:CIVV NIB Yellow Copy:Operator Pink Copy: <br />