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Waste Tire Sui .,dy & Inspection Report . Inspection Report Number ■ <br /> State B CaliforniaCIWMI 1ew 04/04) - 1144031 <br /> California Integrated 1Was81 tJe Management Board Survey Form - Page 1 <br /> Part A- Survey -_ BLUE OR BLACK INK PEN <br /> I Business Profile Inspection Details <br /> TPID- 7 j ;1 Inspection Type (Fill one) <br /> Site Suffix: ✓ ('",,' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `tel If Referral,choose referral type(Fill one) <br /> Identifier: �]C:11� �t�1:��1.h� c_-E�V►V 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address v l - l C) l � �rni <br /> Ni \)L4 1Or, <br /> Inspection Date <br /> � k CA iq5Qqol G <br /> Time In Time Out <br /> Business Rep Title 4 ®AM *AM <br /> O PM l I cJ Q PM <br /> = G� - -- - - - --- -- - 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 /> . <br /> ® Active 0 Passenger 0 Generator 49 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 End-Use ® Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 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 /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS j <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 m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 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 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 0 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations —� <br /> 0 0 Other § <br /> Comments <br /> Inspection Form Included: 0' <br /> Comments Included: ®; - e - - - - -- - C <br /> Business Rep's gnature Phone Number p, o gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect ( y A M p 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />