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Waste Tire SOV, y & Inspection RepoQ Inspection Report Number ■ <br /> .4 State of CaliforniaCIW <br /> 04104) <br /> cal Porn a Int grat d181 Was eeManagement Board S u rvey Form - Page 1 <br /> Part A- Surve_y BLUE OR BLACK INK PEN <br /> Business 411inspectionDetails <br /> TPID- Inspection Type (Fill one) <br />( Site Suffix: _ �QQ�tp I C� � � LV ® Routine Q Re-inspection Q Referral Q Observation <br /> Local i —� —�— If Referral,choose referral type(Fill one) <br /> Identifier: JGrI TC30 9U Co(AN")�% Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street t" Inspection Date <br /> C� <br /> t,ity states ZIP Code Time In Time Out 0 AM <br /> Business Rep Title __....f 00 Am PM El–`E I <br /> 0 PM <br /> Operational Status Tlfr Business Role �Storage Type <br /> (Fill one only) (Fill all that ap(aly)- (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger":,,'; ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ^� .1 ! Q Hauler Q Indoor <br /> !9 Q Inactive Q Truck <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 (a Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q /Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q14 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 /> i <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 ® In Compliance - No Violations <br /> Q Q Other: § j <br /> Comments (..\nAI.`) s.L�k) (SSMC r eZl ` �1 4 A- <br /> - 1C� iL.:,�C,1 tr' Yl 1 d rYi�%' �1...:: t��P <br /> J ' <br /> Inspection Form Included: Q, <br /> Comments Included: Q p 9Inspector's <br /> Business Rep's Signature Phone Number Si na re Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 7 _ 62081 <br /> 1: .�. l i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />