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Inspection Report Number <br /> Waste Tire Su ey & Inspection Report <br /> L11 Statof California <br /> e '2 - 1006575 Califomnialnegrat d Was eeManagement Board Survey Form - Page 1 1 L 1 0 0 /n�V 5 f'(7 <br /> 5 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: > (� t ® Routine Q Re-inspection Q Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SA.h ��N O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> - --- _ <br /> Business or Facility Name Inspected By Inspector <br /> r'-L.. 3 q n <br /> Physical Adress ( <br /> V ►r ct,�c- �- <br /> _ Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> . Z O Q PM 5 <br /> ' PM <br /> - - _ - - ;Operational Status Tire Type <br /> BuRole Storage <br /> Tae <br /> Tire Count (Whole/PTE) V (Fill one only) (Fill all that aPPIY) (Fill all that apply) ( all apply) <br /> Q Active ® Passenger Generator ® Outdoor <br /> Latitude D Q Closed 0 Altered <br /> GP$ Q Hauler O Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer ® Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder O 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. 1 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 /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orDtT) <br /> 0 ! 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ..,_ ;r <br /> O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 'Q Referred/CIWMB me <br /> Enforcent <br /> O O 1 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 1 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I ® In Compliance - No Violations <br /> Ocher. § i <br /> _ ----- - <br /> Comments <br /> fie, <br /> °�- <br /> i - �`t �b w R <br /> ((,t, r,_t w Un(�vti -f s�'� o �� r 3 �.Lcr�S r -- -(C.�v i t,w L'l L Ci ►�-e w�.e <br /> w o _ W D Q 1­4 a.. <br /> Inspection Form Included: Qi <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature hone Number <br /> INSTRUCTIONS ON BACK rCorrect Incorrect' rN 1 E',X A * PjLrE; 1 1 2 3 62081 <br /> r1 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />