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Inspection Report Number <br /> ° _�_- WasteaTire ey & Inspection Rep <br /> p p <br /> ■ 6iwsIDState of n ,i It -f, .gj A <br /> CWMB 04/0 <br /> California Int grat dt81 Was eeManagement Board survey Form - Page 1 - <br /> Part A- Survey__ — BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ]� i �� `� / Inspection Type (Fill one) } <br /> Site Suffix i Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. <br /> (��_, I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> Physical Address <br /> Street <br /> / Inspection Date <br /> City State Zip Code Time In Time Out <br /> Business RepTitle 0 PMIM O AM <br /> ` � � El <br /> PM <br /> Operational <br /> Operational Status Tire Type T Business Role <br /> Storage Type <br /> (Fill one-only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/P'I'E) <br /> 0 Active Q Passe <br /> n <br /> ger Q Generator Q Outdoor <br /> OOClosed QAltered <br /> Latitude Q Hauler Q indoor <br /> GPS 7_ 1 Inactive Q Truck <br /> OQ_ T <br /> Longitude — Q Planned Q OTR Q 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 0 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 MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 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 / FTI / 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 Q In Compliance - No Violations <br /> O O 1 Other: § <br /> Comments <br /> Inspection Form Included: Q, <br /> Comments Included: Q Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �/ E X l A Alli,-' l-,E�.1 f- <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />