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Waste Tire Su )y & Inspection Report inspection Report Number <br /> EiRi' State CIWMB California I 1 - 1140961 <br /> 04104) <br /> California Int grat d,81 Was eeManagement Board Survey Form - Page 1 <br /> Part A-_Survp_y BLUE OR BLACK INK PEN <br /> Business Profile 7 Inspection Details <br /> TPID- j r i _ I Inspection Type (Fill one) <br /> Site Suffix: ` r ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Salo (��A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '�^�`^ Inspected By Inspector <br /> %'ZC pa�G <br /> Physical Address <br /> /jc'l cv1-7 Rd . <br /> Inspection Date //) j 0 I ` 0 <br /> Time In Time Out <br /> Business Rep Title © 3 l ® O AM Q 0 AM <br /> ® PM PM <br /> Y4"-K <br /> / <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 ® Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - 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 /> i <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 • Other <br /> _ Alw/4' •Al41r <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. I 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 <br /> in Compliance'- No Violations <br /> Q Q Other: § <br /> Comments <br /> InspectionForm <br /> Q � J , p t7--Comments Included: <br /> Business Rn ure ns ector's Si niure <br /> Phone Number one Number <br /> 3 <br /> INSTRUCTIONS ON BACK �tt°et� °� t" tt� �° k . 11 2 <br /> 62081 <br /> . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cok:LE <br />