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Waste Tire Su, -%y & Inspection Report ,Inspection Report Number <br /> ■ E17Ji State of California ■ <br /> California Integrated Was eeManagement Board Survey Form - Page 1 Il - 1140758 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C �1 Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t t '-'�iC.� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or <br /> Facility Name Inspected By Inspector <br /> Physical <br /> --- <br /> Inspection Date 1 0 <br /> Time In Time Out <br /> Business Rep Title O AMr O AM <br /> 0 t 3 ® PM 1 3 v (8PM <br /> _Tcyv -- - — — 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 /> ®Active ® Passenger ® Generator Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive (a Truck <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 Q Hauler ®Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VVI A HAULING AND MANIFEST REQUIREMENTS <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / 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 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 I 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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1 <br /> 2.[�i Y�]�•s��j�.�E%%1�"j`CJLI� CJ"1^.. '7L[i� ��K�,L-IiL�`r� ��t-L <br /> 00, <br /> Inspection Form Included: QIP <br /> Comments Included: Buss p's nat <br /> si Sigure Phone Number InspectSignatt Phone Number <br /> - -- <br /> INSTRUCTIONS ON BACK <br /> Correct:� Incorrect \� ✓� (W , j E 62081 <br /> ■ White — - _ ® ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink opy: EA <br />