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og��s�;oogo <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> StatectCal"°en'a Survey Form - Page 1 1 9 1 4 7 9 1 4 9 <br /> LIWMB 181(New 9. y U <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details • . <br /> TPID- fT 0— Inspection Type (Fill one) <br /> Site Suffix: I 51 it Routine Q Re-inspection Q Referral 0 Observation <br /> Local %�C / If Referral,choose referral type(Fill one) <br /> Identifier: -J/ �`� SGS Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1V1 Inspected By Inspector — <br /> Physical Address <br /> 1 LU'e{�(,(r(� 0 ,C�(�`y <br /> Street /� p� Q 1,91 <br /> �1 laj CN'_ J / Vy n� 336 Inspection Date U 2 V o <br /> �/` / v % I Time In 'rime Out <br /> city State ZIP Code <br /> Business Rep ^ Title O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> iFill all that apply) Fill all that apply) Fill all that a <br /> Tire Count(Whole/PTE). (Fill one onl y) ( pp y) ( PPY) ( apply) <br /> 0 Active ®Passenger. ®Generator O Outdoor <br /> ,O Q Closed Q Altered AM <br /> GPS Latitude I ) -i - - --I—i Q Hauler Q Indoor <br /> 0 Inactive Q Truck <br /> Longitude ! Q Planned Q OTR O End-Use Q Container. <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair ®Trucking Fleet 0 Government .Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture O Shredder 0 Other I 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler.Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date[]] <br /> It m / m <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> i Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O Q 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 /> 0 Q 1 Other: §` e I ` <br /> Comments 0&es !�_t o My C/1a _krmS <br /> �a buy °Ajd r hAtA, a� /0 61- M6VT des . C_�t W <br /> leAn t sjU-e are_�o�a rd dogs Wqot� oye <br /> .Ks cNf 4 r <br /> Inspection Form Included:®/ /�A/ � / D�� a(� Q q <br /> Comments Included: /yl as -f aSSV& q&0 <br /> 18 ust s Rep's Ignature Phone Number Inspectors Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(J) X A MJPILIEJ 111,213 162061 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />