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Waste Tire SL- .ay & Inspection Repor, Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 0 6 61 <br /> California Int gr ed Waste 181 eManagement Board Survey Form w 04104) - 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: ` r 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� 6yC��� If Referral,choose referral type(Fill one) <br /> Identifier: -'S <br /> ��_ � \,V\ 0 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address in o A,, <br /> Inspection Date �ji , C) / <br /> CA <br /> Time In Time Out <br /> Business Rep Title ) ��••--��y� 0 AM ,ry 0 AM <br /> ( V PM Cd 0 PM <br /> --- -- --- - - - - - - -- Operational Status Tire Type 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 /> � (� <br /> Active Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 10 New Tire Dealer 0 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / 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 O <br /> 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 C <br /> Inspection Form Included: QI 0%C. <br /> Comments Included: V�! / <br /> i Business Rep's Signature Phone Number ure Phone Number <br /> INSTRUCTIONS ON BACK Correct * Incorrect I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator ® ■ <br />