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Waste Tire ry & Inspection RepA41nspection Report Number <br /> ■ �Ai; State of CaliforniaCIWMB T Q ■ <br /> Calif Int grat df81 Was eeManagement Board Survey Form - Page 1 y 1 2 7 6 9 .J <br /> Part A- Survey- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ Inspection Type (Fill one) <br /> Site Suffix: t V J O I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �-- If Referral,choose referral type(Fill one) <br /> Identifier: Is6k(� J oay1�\(� C��,t� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address Exp ccss 390A La�Cr <br /> S� 5 ^S Inspection Date I � � q � � O(\k0n d�✓ Time In Time Out <br /> Business Rep ` Ti�tcl�eO AM C [ O AM <br /> � � � � � PM � ' J J � PM <br /> �+-- --- - -- -- - 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 /> Active Q Passenger ® Generator (9 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler ® Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - End-Use Container <br /> 0 Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ; A I HAULING AND MANIFEST REQUIREMENTS <br /> I® <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date® / / I <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> • O --- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O Other: § - -- --� <br /> Comments i <br /> ��rle,=�Ll '�U��J`�t7-tsnQ_.(��n��- �a_p_l�"►__ a �l�v�_�lu_�.5- �(2�ec�: <br /> Iq t(,O0� vcffIG ni <br /> Inspection Form Included: Q,li <br /> Comments Included: _-`� �' �, -I <�`vv`V - 01 <br /> oJ <br /> Business Rep's Signature Phone Number (a <br /> Inspe or' ignature - Phone Number <br /> y�� � <br /> INSTRUCTIONS ON BACK Correct: Incorrect "� l X 62081 <br /> P S 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py:L <br />