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Loa@ Waste Tire Su&Ay & Inspection Report Inspection Report Number <br /> State B California Il - 1140558 <br /> 04104) <br /> California Int grat dt81 Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey_-- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r G „3 U :2 ( 3 ' ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�A" et"o"" V 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name � Inspected By Inspector <br /> Physical Address -3 <br /> 80 <br /> E . L.vrc t,, Pj <br /> Inspection Date <br /> (p y <br /> Time In Time Out <br /> Business Rep / Title 1 O AM0 AM <br /> O PM 0 ® PM <br /> r Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude _ 0 Hauler Indoor <br /> O <br /> 0 Inactive Truck 1 <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 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 0 Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> C11����C�►`ctvy.,-_ QY�- �r`S G�LC�� �/y�(,�.t' `� <br /> A _ 1w LAr -f'/G <br /> Inspection Form Included: 0 <br /> Comments Included: ® ���" e32-OjJ7b - ���,i, b0�-Q(�Z3 <br /> Business Rep's Signre Phone Number Inspecto ' Signat Phone Number <br /> INSTRUCTIONS ON BACK Correct:IP/incorrect: X' Zfi �/ 1 , VP 2 62081 <br /> While Copy:CI M Yellow Copy Operator Pin Co :LEA <br />