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08032040220 <br /> €r- Waste Tire Survey & Inspection Report Inspection.Report Number <br /> etre suteofearromla <br /> Gr <br /> CIVYMB Waste <br /> eManage) Survey Form - Page 1 1 S - -1 4. 1 0. 5 9 7 <br /> Califomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> � TPID- � � .� � � � � Inspection Type (Fill one) <br /> Site Suffix: Q t4 QRoutine ®Re-inspection QReferral <br /> Q.Observatiori. <br /> Local If Referral;choose referral type(Fill one) <br /> Identifier: 5&1^ 70�— �U O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ~ �l Inspected By Inspector <br /> Physica Address e�O T(DDL [�R] - <br /> =] I��y D b0yz;k0 I <br /> Street <br /> C,p ; /� , 9 _0 Inspection Date <br /> I Il'/at 5a3� <br /> City Mate LIP Code Time In Time Out <br /> Business Rep Nlar�j CA _ (1 + Title 0 PM m m 0 PM <br /> I AVIA�O �� DY "� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) e I _ -1, <br /> E J-5 (Fill one only)' (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger (0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude �. Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O 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 /> ®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 l I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A !HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O — -... <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 C-III Enforcement <br /> O O 14 CCR§18461•-Manifest System Requirements for Waste Tire End,-Use Facilities <br /> O Q• 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O Other. § <br /> Comments �e—Jl yl UC:fift JU5 e . aTL 11/IGlYiit. e'S+ f;V- Vl S <br /> taa,d ddQ! en� v ov td . -Pada: )a- 1yrt _LNX �pos is h4w&Jer. k.e_ <br /> o(i_lloL tq y 5�o fo Gari fy'rv� . N_o ✓%Ola tr'ons ofeo(. <br /> es-fi Gg4s, For 3 c& <br /> Inspection Form Included:Q <br /> Comments Included:Q z qq3 q <br /> -77 a �6q6 <br /> Bp Phone <br /> Number InspecLoA Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: III rtcorrect: E62081 XA �dfP :LE 1 23 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy.LEA .■ <br />