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Waste Tire Su, ;y & Inspection Report inspection Report Nu .der ■ <br /> State of California <br /> CJWMB <br /> 04104) <br /> I 1 1140990 <br /> califomia Ine grat dfWas eeManagement Board Survey Form - Page 1 <br /> PartA-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- v Z Z Inspection Type (Fill one) <br /> Site Suffix: S A Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> c <br /> Identifier: LAYN —TbCtG„ i to Ca Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Qum 1-y ca,-f,, -S Q <br /> Physical Address - f � � Vt1CiY�1,�Crtiv <br /> a7� vCc) �cuv�li 'fid - <br /> Inspection Date <br /> �^rct v� CA �.�3� T <br /> y Time In Time Out <br /> Business Rep Title -J 0 AM t ' Q AM <br /> �PX 1M`YI�Q sZ 0 PM O Lf ® ® PM <br /> ia4l Y) s S+ru.f k we -r S <br /> Operational Status <br /> — — — --- p I 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 /> ® Active Q Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned i Q OTR Q End-Use Q Container- <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 /> 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 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 0 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 /> O 1 Q Other: § <br /> Comments <br /> C2,,,�•�;�,. ... �,��,�,��� � -yds s �(.t��� c-�� <br /> — fD It QW r n- A JV6 9 - - — — -- <br /> Inspection Form Included: Q <br /> Comments Included: -_._._.._�'�®���6� �3 <br /> B sI s Rep's ignat r Phone Number nspectoes Signature Phone Number <br /> — --- - — - 62081 <br /> INSTRUCTIONS ON BACK orrect: Incorrect: X Y E A E ) Z 131 <br /> W e Copy:CIWMB Yellow Cop O, ra Pink Co 'LE ® 0 <br />