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Yy�ste Tire Survey & Inspection Report inspection Report Number <br /> ClWMCalifomia Survey Form Page 1 19 - 1 0 7 3 5 4 $ <br /> CIWMB 181 stew nage <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business.Profile Inspection Details <br /> TPID- FInspection Type (Fill one) <br /> Site Suffix: � .� S - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: µl / _-,�,�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _a Inspected B <br /> P Y Inspector <br /> I G_6S.C'_l_x_A�,,,, 13 <br /> Physical Address I <br /> I 20 20 S._AIY—pv-(_t Wt.v�T I <br /> Street <br /> Inspection Date <br /> ICi-tv CAO}-'UYn LA S 41 1 T <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> El ' m® PM IT—] ' m ®PM <br /> Operational Status Tire Type Business Role Storage Type . <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count.(Whole/PTE) i l I t <br /> 0.l ®Active ® Passenger ® Generator . ®Outdoor <br /> O Q Closed Q Altered . <br /> GPS . Latituder ! Q Hauler Q Indoor <br /> - <br /> ` --I. L-�� Q Inactive ®Truck <br /> O <br /> Longitude - I Q Planned OTR Q End-Use Q Container <br /> Business"Type (Fill all that apply) JJJ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility KENEGRGEME1T 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 <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 forNOV 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 I 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 /> Comments ((���s-1/_�u-c�l�aca�lc+�___ k <br /> irrc )rea�vr�tt7 4.r�rox,_(LaQ._.3�2►v�.x►=.—�Ycs obscac�.J---�a'Fc—ll�a-ua`vla,�w�,c <br /> Inspection Form �nc <br /> ncluded: Q <br /> Comments luded: Q X/G% _119714 -07 /!�! L6 -od z3 <br /> Business Rep's Signature Phone Number nspector's Signature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: J X ,a M P LE' 1 ;2 3 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />