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pan Inspection Report Number <br /> Waste Tire Survey & Inspection Re <br /> Slate or CalHornia Survey <br /> form <br /> �O rryt . Page 'I 3 - fl 4 4 9 <br /> cwme 141 u lHew 617041 1 <br /> callfomia lntegralad Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- p �^ t Inspection Type (Fill one) <br /> Site Suffix; 9 B .1 1 l� Routine Q Re-inspection ❑Referral ❑Observation <br /> Local [[�� It Referral,choose referral type(Fill one) <br /> Identifier: 51" p'p4�Gr rig � Q CHP Q CIWMB ❑ Complaint ❑Educational Visit ❑Other <br /> Business or Facility Name i/ Inspected By Inspector <br /> Physical Address f 4 edor YI•l+�l/ <br /> J <br /> �p 7 W yode^ Vie <br /> Street I� T r o f ! p <br /> Ins on Date <br /> 64 0!5733 7 <br /> ity State ZIP ode Time In Time out <br /> Business Rep Title [a] <br /> �FM ' n :� 0 AM <br /> vL +♦ PM <br /> L�a L�p frn4•sr 2� G`" " <br /> _ Operational Status Tire Type Business Rale Storage Type <br /> 1 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count[Whole/PTE] ' t , f <br /> i O *Active Passenger 0 Generator 0 Outdoor <br /> Altered <br /> Latitude <br /> GPS Latitude { + i. ' i ❑ Closed ❑ ❑Hauler ❑ indoor <br /> - a Inactive ❑Truck <br /> ❑DTR Q Q Container <br /> 4 <br /> Longitude � , I , ; � + i ❑ Planned End-Use <br /> Business Type (Fill all that apply) <br /> New Tire Dealer ❑Auto Repair ❑Trucking Fleet ❑Govemment ❑ Retreader Q Dismantler ❑Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ❑service station ❑ Hauler ❑Agriculture ❑Shredder Q Other l �� <br /> Part B-Inspection of Waste Tire dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS ❑ Notice Of Vlalation ❑Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 4 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-RegistrativrdDecal in Vehicle <br /> ❑ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Cate <br /> a ❑ 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from C1W MB <br /> Q ❑ 14 CCR§ 18459,2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days [Fiequrred fvrNOV ar k <br /> Q n 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§10460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred r CIWMt3 Enforcement <br /> Q ❑ 14 CCR§16461-Manifest System Requirements for Waste Tire Enid-Use Facilities <br /> ❑ 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ! in Compliance - No Violations <br /> ❑ Q Other. § j . <br /> Comments 'XtC. ri.! •+�+ID '1 d acrG� �uJ1 6t1� <br /> w-ri a5 ' xray <br /> Inspection Formincluded: Q D_r- d 4eW d333 <br /> Comments included: 0 —�!RIL�. x- �3 J — <br /> Business Rep's Signature Phone Number tnspec#vrs Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct: incorrect:No E A �A P 1. <br /> 1Ej 111-2131 <br /> White Copy.CIWMB Yetiow Ccpyr.Operator Pink Copy.LEA <br />