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Yy��te Tire SAy & Inspection RepoA*lnspection Report Number <br /> iforniaWMB 04104) <br /> Californ a'Int grat d,81 Was eeManagement Board Survey Form - Page 1 9 - 1 V(j�� /5� 1f'�' 7 1 V V f 4 <br /> Part A- Survey BLUE OR BLACK INK_ PEN <br /> Inspection Details <br /> TPID- D9N - / Inspection Type (Fill one) <br /> Site Suffix: @ Routine Q Re-inspectiop Q Referral Q Observation <br /> Local (" If Referral,choose referral type(Fill one) <br /> Identifier: h j(�( (i1{i� (p ; Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> �✓ �t�, vvJQ11- 0j LLL i r, <br /> Physical Address s"� — <br /> r -5 <br /> Street <br /> Inspection Date <br /> I <br /> C;hi State Ir ! / ZIP Code I Time In Time Out <br /> Business Rep Title O AM Q AM <br /> l l( d ( 0P � ' � 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/ <br /> PTE) (Fill one only) (Fill all that apply)'; (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger Q Generator Q Outdoor <br /> Latitude m O Q Closed Q Altered <br /> GP$ Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> :�� <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business TyP <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 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 m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § - — <br /> Comments'1 - -- 10- T4_ is rr <br /> kQ���ne C / ._d s T G <br /> :'ruler; tr p(k- If leaf ocAmed 1,,4 ��(� � 1 [,zIZOA to r. kc Cak 7,✓F' ����ICP <br /> Cb �G 214 , j 1 r J Izty 3.��� ' D in �-f o j j f��t _�I 1+_�� �c� � ('�r-, � �- <br /> )�� �f �. �•�ICr 1�'}�(r� 4Ct '- ��%r> > F�t-�`�t�(i✓ Y�tkr{�': . �`►1lt�r�<t�I> ,�F� ��i_���'u <br /> spection Form Included: Q <br /> Comments Included: Q - �:: <br /> Business Rep's Signature Phone Number Inspector'sA Sign Phone Number <br /> G20t 1 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X ', p �. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />