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E89 <br /> Waste Tire Su4&y & Inspection Report4plnspection Report Number <br /> State of California <br /> CIWMB I 1 - 114 0 916 <br /> California Inl grat d,Wast eManagement Board Survey Form - Page 1 <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: 3 & O 3 Y v ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:. ���,�}N Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �— <br /> _ / Inspected By Inspector <br /> C� <br /> Physical Address 3 / – 0 / /���' kJ4�l �`a✓"„' <br /> p Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM _ 0 AM <br /> ® PM V ;2 3 J ® 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 MANIFESTEQUIREMENTS , <br /> _....... _ .......---- --_-- --___—.- –.... Q Notice Of Violation Q Extension <br /> O 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 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 EXT) <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § – --- <br /> Comments <br /> - <br /> Inspection.Form Included: Q . <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number `Inspector's Signature 'Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:r incorrect: . �/ A l: (� 112 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: © ■ <br />