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Waste Tire Su_ <br /> %y: & Inspection Repo Inspection Report Number <br /> State of California 1 <br /> California inegrat d Was eeManagement Board Survey Form - Page-1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site,Suffix: Q 5 J O I Routine Q Re-inspection Q Referral Q Observation <br /> Local �a4 <br /> " * �'` If Referral,choose referral type(Fill one) <br /> Identifier: �� 11 W�n� Q CHP Q CIWMB Q Complaint . Q Educational Visit Q Other <br /> Business or Facility Name , -- <br /> ll Inspected By Inspector <br /> Aysical �Address <br /> L-V -_L�(_�2 0���_�. <br /> Street <br /> Inspection Date =01 <br /> L1 Vt LAIN ) Time In Time Out <br /> City Sate ZIP Code r_.r_ ____ <br /> Business Rep : Title O AM r � Q AM <br /> LU�� <br /> ' � PM 3 � PM <br /> GO\ —i <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply) <br /> � � ` �� I <br /> Active Passenger ® Generator Outdoor <br /> losed Q Altered <br /> Latitude 10 <br /> C <br /> S Hauler Q Indoor <br /> t) Q Inactive Q Truck <br /> Q End-Use Q Container <br /> Longitude Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader. Q Dismantler Q Tire Derived Fuel <br /> 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 I I <br /> Part B - Inspection of Waste Tire Dealer,Generator; Hauler and End-Use Facility . T ENFORCEMENT STATUS <br /> V A -=H-A«�..�.r:ULING�A..-�.,,e.«.A.,N IFESTt:R._EQUIREM_.IENTS�._ ZZ1 M <br /> OQ <br /> e: <br /> Notice Of�Niolatlon �_ Extension <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires r: ' m � � d :�� <br /> § 9 P � � � <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Co� p nce$Dradline .thF, <br /> Q Q PRC§ g 42956-Re istration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m%I <br /> P <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q *"'1 �»a Re urred'forMOV,or�DCTjz <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days f� �q� vu <br /> �+ - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs fora years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ,QaRef®rred,/C MBS Ertft�rcerttentg <br /> wn�... l W,**1 <br /> O Q <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 37th 't# gas ua, + #ixarz.r ,4g . <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire•Generators " € ywx "a' � <br /> Q Q �e In Compliance ,�No Viol <br /> O Q �aUons <br /> Other: § Pz� # w; <br /> CommentsQv Q <br /> �o V �.ako�s_a ss c- Gin ccs. <br /> ��tc5.- uu i U�, S WaSC� _aSell <br /> Inspection Form Included: Q ?,/,,� Q�. I- 1 <br /> Comments Included: Os— <br /> -— - - -J�a=u-l�liZ-- ���s <br /> --- -- - 1drines Re 's SI na u e Phone Number ature �./ Phone Number j <br /> 62081 <br /> INSTRUCTIONS ON BACK J0XjAjMjPjLjEj It 12' 3 <br /> White Copy: IWM Yellow Copy:Operator Pink Copy:LEA <br />