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■ , Waste Tire ` u, - ey & Inspection Rer._rt Inspection Report Number ■ <br /> State of California Il - 1140835 <br /> California In egret d WasCWMB 181 te Management Board ew 04/04) Survey Form - Page 1 <br /> Part A-Survey_- _ BLUE OR BLACK INK PEN <br /> liness Profile Inspection Details <br /> I PID- Inspection Type (Fill one) <br /> Site Suffix: t L <br /> Q <br /> I & Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: So^ .�C� L� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> doe, Cr e-y1z_-A-e,_-�, /yvc,� <br /> Physical Address \\ <br /> -7`3-8 5 4) - ���JG'�rl �U .CA TCJJ6 `✓,�l �XJ("l <br /> /��-p2p Inspection Date L L / C) <br /> `�1���� Time In Time Out J <br /> Business Re/p' 1� Title <br /> 1� I �J 4 AM �� 0 AM <br /> �JVC1 G�ri�,11t�5 l�L.(J]'I�i✓ l � �7 � O PM , � � - QPM <br /> - - — -- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> f Q Active Q Passenger •Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 4D Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Ie 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 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 M / m / m <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 ® In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> - -- --- --- - - <br /> ..�pection Form Included: pc90 <br /> Comments Included. _1�8-�� 1_ - <br /> --- <br /> -usmess Rep's Si natu Phone Number �- In ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS N BACK �Correct:* Incorrect: (, 1 AP w P � 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />