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Waste Tire S y & Inspection Reporo Inspection Report Number ■ <br /> W <br /> is � State of California I 1 — 1088299 <br /> California Int grat d,81 Was eeManagement Board Survey Form - Page 1 - <br /> Part A--Survey_— ........... BLUE OR BLACK INK PEN <br /> -Puniness ProfileInspection Details <br /> TPID- j f r Inspection Type (Fill one) <br /> Site Suffix: p �j i S iC3 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: —'r�� �d0 )��,q COUn� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected ByInspector <br /> Physical Address <br /> �LLJ� - p 1 O i Yrlstran- . Lucas i <br /> \ 990 P,c Co l�_._..�d__.. _T <br /> Street <br /> State IP Code Time In <br /> ectlon at Time O_ut <br /> Inspection <br /> Business Rep Title <br /> 0__e O PM _'.�1 O] .. O PM <br /> ctrl <br /> Operational Status Tire?ypeBusiness Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Generator Q Outdoor <br /> . ��_ 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q inactive Q Truck <br /> Longitude <br /> g F7 <br /> Q Planned Q OTR Q End-Use Q Container <br /> - — -- - <br /> Business Type (Fill all that apply) <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 /> - <br /> 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 m m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB l <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 In Compliance - No Violations <br /> 10 O Other: <br /> Comments go OttrC inslI .e.C.--►oYl DLr�Uril �►S dtxl-e 4 OX -jo110win��-��O-h� <br /> Aprox. 61 t,�ca��2�u�ed -tfres -stoceror,- ,l+e. �aclli y W_5 s WiLpon Wnul <br /> t tv"e T -,�r -�S-i- wave <br /> r C Or�cer In <br /> 7OXT <br /> Inspection Form Included. Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number i p ctor's Signatur Phone Number <br /> f 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 'u � V� II- :€,A M j P j � f;a 1 t 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />