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Waste Tire Su ;y & Inspection Report! Inspection Report Number ■ <br /> State of California T 1 <br /> California IntegrCIWal d WasB 181 te Manageew 04/04)ment Board Survey Form - Page 1 + + 1 1. 4 12 18 <br /> Part A- Surye BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- ` � � � L, � �--� Inspection Type (Fill one) <br /> Site Suffix: 0 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 /> l l l i d 7 <br /> Physical Address 1 <br /> i31 i 1 D 40ji kI.�C <br /> Sire t \ s / til75�Inspection DateI L_._.. <br /> City Time In Time Out <br /> Business Rep Title O AM i O AM <br /> OPM _ - 0 P <br /> E III,IT 11111Operational Status Tire Type Business Role Storage Type <br /> Tire Count(VilhOle�Pl'Ej (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f f Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 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 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 1:11 / 11:] / El <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ( <br /> a <br /> aE <br /> Inspection Form trrcluded:'Q � <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ . <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A X j A M.P L.E 1 2 62081, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA e <br />