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Waste Tire SL&y & Inspection ReporS Inspection Report Number <br /> ...4 <br /> ew 04/04) <br /> -� G1Si State of California - i} _� A <br /> California Integrated CIWMB tWas81 te Management Board Survey Form - Page 1 _ _. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> nspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: & O Q ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: "ly 1 J C ' t� -Co ,A t C ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - _ 1--- �n <br /> Physical Address <br /> Street ct 52-05 Inspection Date Q L <br /> CA q <br /> ^;r„ r�z? Time In Time Out T- <br /> Business <br /> Z Code <br /> Business Rep Title I Q AM O AM <br /> 0 P 0 P <br /> - Operational Status Tire Type i 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 Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> lO Q Inactive Q Truck II <br /> Longitude — I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 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 <br /> M / m / 7 <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 ( C <br /> 0 11.1 OA10 �)f't` _ro� rC- �: ,Fclt.,ti �c _ nr1,v PPr­1 f rj-)=j-(A't MCrI7VIID. <br /> 'i`CIA c_,0C_ (_ tri �f:- ;s Avow r% 'c Cf, t,�'�'r '� u)0,4- <br /> Inspection Form Included: Q <br /> Comments Included: Q' <br /> Business Rep's Signature Phone Number lnoector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A�, V } A dM4 Llr 1 E i j 1 ?E <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />