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Waste Tire Soy & Inspection Repor, Inspection Report Number <br /> 7`E State of California ■ <br /> C04/04)alif Int grat di81 WaseeManagementBoard Survey Form - Page 1 Il - 1127485 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Q Inspection Type (Fill one) <br /> Site Suffix: t ►lin! o ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: S(AA Qa4 L( n cou-'✓Iv1` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busin ss or Facility Name <br /> Inspected By Inspector <br /> t e-S Tru- n q _ q I <br /> Physical Address ,1 3 I t V I ��` 1 Est* <br /> � 1 W 1'V <br /> 0� <br /> Inspection Date / <br /> CA 15XS <br /> Time In Time Out <br /> Business Rep Title I u A AM Q AM <br /> 1 eQ l 1 0 PM — 0 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 Q Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> D O Inactive It Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I* Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> 0 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 HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m T <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators A In Compliance - No Violations <br /> O Q Other: § <br /> Comments I p - 1I S I <br /> j10 q AAboor Arws -ol-c(Doofn,- ---- <br /> itII,I,N, <br /> �� a�� ik .-ld,S�S-- —lJ�i 71 rt�, aS �f1Qi r f �STeler �Lu U c�- <br /> v <br /> Inspection Form Included: OI <br /> Q .. -- /1 -j- Q_ <br /> Comments Included: usins <br /> -- - <br /> Signature Phone Number Inspec is Signa u Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ! I X A L I L 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: ■ <br />