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Waste Tire Sur „ay & Inspection Report Inspection Report Number ■ <br /> Lill State of CaliforniaCIWMB <br /> Californiainegratd'81 WastJeManagern tBoard Survey Form - Page 1 I1 1140943 <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> - --- -- -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L/ 7 3 / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addl`gss J J pej3,r3�j/as/ 1'At <br /> Inspection Date / t1 <br /> Time In Time Out <br /> Business Rep Title ® AM t p ® AM <br /> • ///�� 0 (1 rye- O PM16 <br /> T 0 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 ® Passenger (9 Generator Q Outdoor <br /> 0 • Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> 0 Q Inactive j ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> 0-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 Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O 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 / 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 /> O 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�� _ 13l q 4(9-S' .-U /f <br /> Inspection Form Included: Q, O S r_`��6� <br /> �`�-�R7"�4LKk�'1 �/�.c-/i"f•�e��u�,�ive �/tS p--�113� <br /> Comments Included: Q! - --- — <br /> slness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS BACK I Correct: Inc orrect: �/ A , � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />