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Inspection Report Number <br /> Waste Tire Sul & Inspection Repor ■ <br /> YBLG;&:m State of California Il - 1088229 <br /> California Int grCIWat df181 e <br /> w 04104)WaseManagementBoard Survey Form - Page 1 - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> , r'� -- ' nspecon Details <br /> Business Profile�'�y���(9 " a., i � �. Inspection --- <br /> TPID- Inspection Inspection Type (Fill one) <br /> Ct <br /> ]— <br /> Site Suffix: U <br /> tJ ' UD- 1 Q Routine Q Re-inspection Q Referral ® Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S C-,er) UU 11 C I C-O U r)j <br /> QCHP O CIWMB Complaint O Educational Visit <br /> Other i <br /> Business or Facility Name <br /> Inspected By Inspector <br /> -_r Cr , �YIC . __ <br /> Physical Address l — <br /> LU <br /> Street <br /> Inspection Date <br /> o n C_1A _9 5?o6 i k_-- ---- <br /> State 71,E Cade Time In Time Out <br /> Business Rep Title Q AM <br /> # AMO PMEF.. <br /> O PM <br /> - Operational StatusTire Type Business Role Storage Type <br /> Tire Count (wl,oleOPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' Q Active Q Passenger Q Generator Q Outdoor <br /> i <br /> O Q Closed 0 Altered <br /> GPS LatitudeLL Q Hauler Q Indoor <br /> @ Inactive Q Truck <br /> --L— <br /> 1 1 <br /> Longitude — Q Planned Q OTR 0 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 ® Other t' Cl,r(,I <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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m <br /> Q 0 14 CCR§18459.1 -Tire.Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3—Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: -- <br /> Comments T —} C1t Gl�` �"1re�. _ __ XC_We b_QQ_Y. <br /> - -Fol I g t,y-t.tis r,z.C.�"k c)Y) i"G— v�e r� — � <br /> Y mOVP-A _ -i-,rom -Fhz s��-e_ - `r' ---�o1�OW)na tyrAs na7e No -I NYS es observe} <br /> rlrl—S\ e— T:C.aGt,\�j �,G,d tJI _on Co . ryr-no e. un,tee 41K c-d <br /> �.. �y ;=.rr 4 (,.. 4-r \j ew-e � .` �Q VLC��' i ]T_`._ or ckY' DT Lnr1r LAY <br /> — �. , <br /> Inspection Form Included: Q� (1 <br /> . Comments included: Q <br /> Business Rep's <br /> Signature Phone Number Ins ctor s Signature,. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct. Incorrect: X �,. `r{ A , �' 1 3 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> I <br />