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I?, Inspection Report NumberWaste Tire SL*y & Inspection Repor <br /> 6 CW MB 04104) <br /> State of California T 1 1088014[/�j <br /> California Ine grat dt81 Was eeManagement Board Survey Form - Page 1 + + 1 0 `+R g 0 Z 7 <br /> Part A- SurVe BLUE OR BLACK INK PEN <br /> Business Pro Inspection Details <br />} TPID- I 1 t C � � � � - Inspection Type (Fill one) <br /> Site Suffix: —1 =7 V 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �_ If Referral,choose referral type(Fill one) <br /> Identifier: ock q aim �-G rN 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namer _ Inspected By Inspector <br /> CAk \Y-) <br /> Physical Address IT- <br /> 1 <br /> Q � . <br /> � Kr►�tt o►'n L�a� l � I <br /> Street =0 - <br /> Inspection Date / 3 , / O 8 <br /> II �'�e-'nL� �G�� � CA 95 2 I � Inspection <br /> In Time Out <br /> 17ai, State ZIP Code <br /> Business Rep Title ( 0 AM 1 + O AM <br /> 0 PM Q PM <br /> Uv.►'fle!' l - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �j 2 <br /> ® Active Q Passenger Q Generator Q Outdoor , <br /> 0 Q Closed Q Altered <br /> GPS Latitude WQ Hauler Q Indoor <br /> o Q Inactive Q Truck <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@ Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 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 / 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> R.aut►n¢ ,r �a ct,orl caAJC,Tnr�%t thlS "e 4 o I�yt <br /> orr>� 11:` n ted <br /> F�;��> � m r�,t u�ccl t"ILTK Gs �o=fie T� ho,�1�� '-dn (2)-7 S <br /> ao . -5red Frctclo I bro er G abr O Frodo s,et - aul +irt!; <br /> _tntl o � Irct "4-, T _ n -two <br /> Inspection Form Included 0 I <br /> Comments Included <br /> L BuE*Kess Rep's Sig ture T Phone�l�lumber Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X s/ Qff'&�Xj,A M I P I L I E 62081 P 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />