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01e' y & Inspection Inspection Report Number <br /> - <br /> Waste Tire SiRe or <br /> State of CaliforniaClWM13 81( ew 04104 - <br /> Calfomi�alnt grated,WasNeManagelmentBoard Survey Form - Page 1 _'. � ®.. ' fa <br /> Part A Survey _ BLUE OR BLACK_ <br /> ts►t>7esn _._ _ �� �� " Inspection Details --- -- <br /> Site Suffix: { 1-1H "� [K(ilLO-1� Routine Q Re-inspection Q Referral Q Observation <br /> TPID- Inspection Type (Fill one) <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sqn To t_-A n C dU1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> FBusiness or Facility Name Inspected By Inspector <br /> Physical Address I - t ,r �,• <br /> Street Lq <br /> Inspection Date <br /> Ca"ty State ZIPCode Time In ] F <br /> _ Time Out <br /> Business Rep Title r 1 0 AM 0 AM <br /> , O PM O PM <br /> Lel.�lfi(,--L�---..-,�-.-(�i-�j-q"�A�---.-.--- w, V', <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered ' <br /> GPS Latitude > Q Hauler Q Indoor <br /> ff <br /> Q Inactive Q Truck <br /> T_.,_t �-_- O <br /> T__ — i <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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§4295,1 -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 <br /> M / M / 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 /> Q O <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 /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q ' Q - em <br /> @ In Compliance - No Violations <br /> Q O Other: § <br /> Comments <br /> RA '; _ F�A_L►�_�-�__+, <br /> �+'1-G1�1 `_ V t�v lt✓l — �_L-C2-(�� 'Cr n;I 1` -. ��CZ�(�� f1� r� � .,._� r►Y r s r'r; <br />} i <br /> 'a ► <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number , <br /> INSTRUCTIONS ON BACK Correct:01 incorrect: ( ,, ' k`mi P 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />