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Waste Tire SLW- y & Inspection Rep®Q Inspection Report Number ■ <br /> State of California I 0 7 9 - <br /> California Int,WM13 181(NeManagelment Board Survey Form - Page 1grateI � _ <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business;Profile ( Inspection Details <br /> - _. - - - - <br /> _ . <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: j '� �� j Q�- Q Routine Q Re-inspection Q Referral 6) Observation <br /> Locali If Referral,choose referral type(Fill one) <br /> Identifier: �j{�Cl �1 O Q G{ ! (1 C_U u�At Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 1=0 L, -1 <br /> Street T <br /> p [g]-6-1 / 21c,� / <br /> Inspection DateLc_) Les <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title � : =0 AM ( 7 0 AM <br /> L 0 PM 0 PM <br /> Operational Status! tl Business Role Storage Type <br /> (Fill one only) til°' (Fill all that apply) (Fill all that apply)' <br /> ® Active Q 6) Generator Q Outdoor <br /> Latitude Q Closed Q'A feted" <br /> CIPS Q Hauler ,Q Indoor <br /> Q Inactive Q Truck <br /> Q End-Use Q Container <br /> Longitude Q Planned Q OTR <br /> r uslness Type" r <br /> Q New Tire Dealer Q Auto Repair 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 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 m / F11 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 /> 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 /> r cCTrVAVC_ Iina CIS CAC�tfIfe-cl �,y_tuC 'AC`n ci 7�1 r -wcl,s - <br /> Inspection Form Included: <br /> P O' <br /> Comments Included: Q pSignature - " 9 <br /> Business Rep's Phone Number Inspector's Signature Phone Number J <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X r: 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />