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i«= Waste Tire Survey & Inspection Report Inspection Report Number <br /> ere_ <br /> Stab II California y 9 16 - 1 01 0 51.5 <br /> Cg.to iO(.M.-iiq Survey Form - Page 1 <br /> Califom4lntegmteE Waate Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I1 ,41 q 31 &1O O Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local Il��nn nnssy��(^'/j')`N 1 If Referral,choose referral type(Fill one► <br /> Identifier: "rlJ` (j(77/L Q CHP Q CIWMB Q Complaint Q Educatonal Visit Q Other <br /> Business or Facility Name V <br /> Inspected B <br /> Y Inspector <br /> ( 961fes(�D P�Snn 4 <br /> PhysicalAddress <br /> 3 9 I v I �`Lvt Gl/l I ' t CrJ t- <br /> Street <br /> � <br /> C4State <br /> Date <br /> rty ✓, tate ZIP COCT.i Time In Time Out <br /> Business Repm0 AM <br /> ^ Title AM <br /> tUrV� �T r t �1J11Qi� � 0PM m'm M <br /> t— Operational Status Tire Type Business Role Storage Type- <br /> Tire Count(Whole/PTE)7U <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I I e __..__ lIfi0 Active ®Passenger ®Generator ®Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude - FF <br /> Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader ®Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer .0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V . A I is ND AN - REG2 IRE EN Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ( ed iii for NOV o E)C� <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred I CIW MB Enforcement <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Other: § <br /> Comments iyt5 U(y_n cN-�s �fate �� �� �,, <br /> Vf" ' k0 <br /> f LC tiw r l06 Qfe <br /> V'tc_"g_ s Q -Fa— _5a� .T'Lrns 1,Lre_a_A;r_acs c_bd_' ds kndw_ <br /> velLalp-� 7T)t' <br /> . rS_Gt-P oh riwl , X10yiollc& S rested . No 7`�►'�S' <br /> v e. !a t_i ci _�1 ire ►gym Ccs( <br /> Inspection Form Included:Q 22I_/ <br /> Comments Included:Q � �sG06� 41-1& <br /> Busin s�Signature Phone Number Inspec s Sig ra Phone Number <br /> INSTRUCTIONS ON BACK o e rest 62081 <br /> ■ EXaMLEA <br /> 07284040002 While Copy.CIW MB Yellow Copy:Operator Pink Copy:LFA <br /> 1 <br />