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Waste Tire Su. .ey & Inspection Report Inspection Report Number ■ <br /> FEBi State B California Il - 1143782 <br /> California lntegrat dWas181 teManageew 04/04)mentBoard 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: ` Q Routine Q Re-inspection Q Referral ® Observation <br /> Local `` //�� If Referral,choose referral type(Fill one) <br /> Identifier: 1� J �" 1.�� cou& Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or FacilityName Inspected By Inspector <br /> Ph�sicel Address - 1 Qi 6,o A,-m6 <br /> Inspection Date Cz / <br /> L <br /> Time In Time Out <br /> Business Rep Title ® AM O AM <br /> O PM t Z l J 0 e 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 1�(�j� *64 <br /> GP$ Latitude �U/ Q Hauler Q 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 /> a New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> j 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 <br /> m / m <br /> 010 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 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 /> 44 <br /> Inspection Form Included: 0 <br /> Comments Included: - -- -- - Acc <br /> Busines Rep's Signature Phone Number Iure Phone Number <br /> INSTRUCTIONS ON BA K Correct Incorrect X N L I <br /> E X 62oa1 <br /> ■ <br /> White Copy:-- - <br /> y:CIWMB Yellow Copy:Operator Pink Co y: <br />