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01262060016 <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> '°r SItc°,1a"r°`°� Survey Form - Page 1 1 4 - 1 01 0 5 7 <br /> SO, 1st(New 041041 <br /> Califomle Integnted Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �l m Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: L-IX4,L—jo-a-e��__/ ltl,. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name vv"LV inspected By Inspector <br /> LBOAV_a'_hV_ <br /> Physical Address D 1 T/ oFf La e—L, � <br /> Street o g l o 0 7 <br /> _ c Inspection Date <br /> CityJ` fare ZIP Code I Time In Time Out <br /> Business Rep Title 0-Row <br /> O AM <br /> �an SDk A T.l��ONJ ---�tL�Y(•✓f.l�/'tF �•m O PM �• O PM <br /> - - - Operational Status Tire Type Business Role Storage Type- <br /> i ` <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> f r k a ®Active Q Passenger *Generator Q Outdoor <br /> I 10 Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude - i Q Planned Q OTR Q End-Use ®Container <br /> Buslness Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair ®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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other 1 I <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FTI / [11 / m <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 (Required for NOV a EXT) <br /> Q 0 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 1 CIWMB Enforcement <br /> Q 0 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 Q Other: § _ /f <br /> Comments4LA e t i u fDIID! ll � a's hOf�CC S <br /> �Ses IO�i1 t 4.1-At ��11t_� C4, b_r► t Qsf T-Orms VieH/_vdt. 6t(4 <br /> !S I ),K,4eD2_ et/_'._tt��CT�wtartiiFeS_ .�r>�IS11�+��e �o� <br /> Inspection Form Included:Q f <br /> Comments Included:® t.SI9+n ,.I Businessep, Si Phone Number Insp� Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct: incorrect: JEjXjAjMjP1LFETUT3 szast® ■ <br /> While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />