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Waste Tire SL 'y & Inspection Repor _ Inspection Report Number <br /> State 1WMB California Il - 1086923 <br /> 04/04) <br /> California ane grat df81Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile 'g Inspection Details <br /> Site - ' FLI <br /> 19bild <br /> r , Inspection Type0(Fill onspOOSite Suffix: t� Routine Re-inspection Referral Observation <br /> Local I C If Referral,choose referral type(Fill one) <br /> Identifier: L- (�. t , 4� ` �� ( i ' tO CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name r - <br /> r <br /> Inspected By Inspector <br /> IrvCI��t _ <br /> Physical Address �; <br /> 7A (-t <br /> ` ,v tfilrl �rIIE �L I <br /> Street ��< �IT67 <br /> �- <br /> -1 � _, Inspection Date ; <br /> l J < Com, �`�L�I ,- <br /> c i„ State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> WWI <br /> Q PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 1.) Active 0 Passenger Q Generator 0 Outdoor <br /> m O O Closed O Altered <br /> GP$ Latitude Q Hauler 0 Indoor <br /> O 0 Inactive O Truck <br /> Longitude - I Q Planned O OTR O End-Use 0 Container <br /> -- <br /> , Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler Q 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 Q Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q O Other: § <br /> Comments <br /> Inspection Form Included: O �.r,• <br /> Comments Included: }' <br /> Business Rep's Signature Phone Number Inspectors Sigrlat re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A ,+�,i I E; 11 1 �� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />