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Waste Tire purvey & Inspection Repo" Inspection Report Number ■ <br /> FIl97 State of California <br /> B 181 01114) <br /> I 1 1140746 <br /> California lne grat dWaseeManagementBoard 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: ` 9 ' Q , e Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: Qt1 J o„Ga; C��n- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ne <br /> Busiss or Facility Name Inspected By Inspector <br /> TtjT Pam SGIeS -11)C. ? <br /> Physical Address _ ' 0 I PJen Escoy <br /> o Ave-, <br /> 95330 Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 0 AM Q AM <br /> 0 PM � � 0 ® PM <br /> - - - - - - - -- -- Operational Status Tire Type f Business Role Storage Type <br /> Tire Count(Whole/PTE) I t I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f * Active Q Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude • Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair 0 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 /> 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 li 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 / <br /> Q Q '14 CCR§18459.1 -Tire Program ID Number from CIWMB II II„ II <br /> 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 i 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 1 Other: § L <br /> Comments �0 1_ W-{A._A� � _C._ n r L S{'�l__ t1� I ( S �CG Q, <br /> Inspection Form Included: ® l t� LL <br /> (�Oq <br /> Comments Included: A Gl' <br /> Business Rep's Signature Number Phone <br /> �negNumber hl PrQu <br /> — - - - � - - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect E X A M L 1 L 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y:L A © ■ <br />