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Waste Tire Sete & Inspection Re o* Inspection Report Number <br /> La <br /> : State of Cali81 fornia Y tI - <br /> California lne grat dCIWMB'WaseeManagementBoard Survey Form - Page 1 4 9 2 2 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t J�.I ' I 2I Li Fo I I ] * Routine Q Re-inspection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: CaC\ Ti)^4CjUIn Cou��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address } — <br /> snc. . 13,q Ko <br /> 1 �r15�'la LucgS � <br /> I i 1950 HcAr\an <br /> Street / Q <br /> Inspection Date 0 f 0 � ,fJ.( <br /> i LCk+n fn IP <br /> City I tate ZIP Coe Time In Time Out <br /> Business Rep Title � 0 AM 0 AM <br /> 1 0 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The 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 /> EDOQ Closed Q AlteredGPSLatitude Q Hauler Q Indoor <br /> Q Inactive Q Truck ��f <br /> Longitude — I I Q Planned Q OTR Q End-Use Q Container/ <br /> Business Type (Fill all that apply) Ford-�� <br /> Q New Tire Dealer Q Auto Repair Q 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 0 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: § 11 / [ <br /> Comments 0`( S Jai, -) -- <br /> o11c���c,�� cscv� cd : oC. �A Nn a lo(4) je 0 Q, %P nr(at Of7 <br /> uses -rnl�nd_ :I:ncl I A st r 1_Q1 rTtte_�lor1-ins - <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signa i <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X X A L.F_- 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />