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Waste Tire 49ey & Inspection Repo Inspection Report Number <br /> -`f!f State CIWMB California I 1 - 11413 4 6 <br /> California Integrad'Was81 tJe Manageew 04104)ment Board Survey Form - Page 1 <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details - <br /> TPID- 7� Q Inspection Type (Fill one) <br /> Site Suffix: ` r� C� f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �a r 1�l (�`� c �_ l✓�, r� Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> -- - <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad ass 39 <br /> - � ��yry,��✓I C� <br /> W?f ) l <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM ( C/ QPM <br /> �(�(,l�l(C` f lL',I C t�YYI(."�v\, ���'► .S i��`�C� - --. -- <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 /> f c, I* Active a Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude - 0 Planned ® OTR O End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ® Other <br /> �LCL Is� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> -- - -- - - Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 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 0 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 40 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments )y. lfe__f )J; _k <br /> no Ac, <br /> - <br /> Inspection Form Included: O; J ,������ <br /> Comments Included: Q LVIt4--- <br /> Business Rep's Signature Phone Number - -Ins0ehto s ignature Phone Number <br /> µ:. <br /> INSTRUCTIONS ON BACK ' Correct: Incorrect: � ��� hly �1E1 1112 3 62081 <br /> White Gov:CI'JVMR Yc,llov,, Copy Operator rink Copy:LEA <br />