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07312040412 <br /> L Waste Tire Survey & Inspection Report inspection,Report Number: <br /> -C=.. <br /> Survey Form - Page 1 1 1 - 1 0 10 5 8 4 <br /> CMfMB 161 stew nage . �/ <br /> Callfomia Integrated Waste Management Board J <br /> Part A-Survey'. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ ^ A Inspection Type (Fill one) <br /> Site <br /> Stte Suffix: o[ 1 r U e Routine Q Re-inspection Q Referral Q Observation <br /> LocalLb—a4 <br /> If Referral,choose referral type(Fill one) <br /> Identifier: <br /> V <br /> •Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility NameInspected <br /> �,� �j ?y./+ Inspected By Inspector <br /> PhI ysical 7Cddress�i"—"«+l.�—1—.LJ rl I_1. 3 9 <br /> Street V` -A-G <br /> L - �,j�� 9S Inspection Date <br /> iW' 1! ( J State ZIP Code Time In .Time Out <br /> Business Rep <br /> Title <br /> ,�/�� / O AM O AM <br /> I I�O�t/ QI L_QJ - /�( .�—J m:M O PM EET <br /> m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> [],.[17 <br /> 1 ®Active Q Passenger 0 Generator Q OutdoorAJ <br /> O QCQ Hauler Q Indoor <br /> losed Q Altered <br /> Latitude m. <br /> GPS 64 <br /> O Q Inactive 0 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other _ <br /> Part B-Inspection of Waste Tire Dealer,Generator Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V { HAULING AND IFEST REQUI EME TS <br /> I 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 <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 (Requlied Ior NOV or EX77 <br /> Q Q 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 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 ®In Compliance No Violations <br /> Q 1 Q 1 Other: § <br /> Comrments Rauitxe1rls� �e_C —LQy_�..— : f�-kv / s / Y�Qy -_ya_e <br /> Jo'- waSe VP� s -L—-ed <br /> _JUo w5 ara Stored on Fik' 4 - �Ja <br /> Inspection Form Included:Q 0-10 <br /> '` (y !_ <br /> Comments Included:Q Isat '168 <br /> � ,916� <br /> Business Rep's Signature Phone Number lns�phors I ure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Ineorrest: IEIXIAIMIPILIEI <br /> 62081 <br /> . While Copy.CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />