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its=- <br /> Waste Tire Su ly & Inspection Report , Inspection Report Number <br /> State of California <br /> Cg <br /> rated 1steMana a Survey Form - Page 1 1 7 . 1 0 2 8 8 8 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 3 5 G °l 3 (V 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ��� JQc-AQ W-,i. COL Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> co�1 cnft AV <br /> Physical Address <br /> 1 Va l `70 <br /> Cf <br /> V Inspection Date <br /> Fr9 VILLA Cake �i_5 1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> paxe-l" 10-AaAt Sew VIU Mir <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ® Active Q Passenger (&Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> D Q Inactive 0 Truck <br /> Longitude — Q Planned j Q OTR Q End-Use Q Container <br /> I <br /> Business 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 ® Other �� � �Qltt�prV� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityNFIhMENT STATUS <br /> _ <br /> V A HAULING AND MANIFEST REQUIREMENTS i _ <br /> Q Q I Q Npt14 Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires I <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Co IIjlY1t 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 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> Q Ql;h� quired for NOV or EXT} <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days s,.;; .,, <br /> .......... - <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years t <br /> Q Q . 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q f tt rl d 1;IWMB 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 <br /> #� t �Il.0pas No Violations <br /> Q Q !Other: <br /> § <br /> Comments l,tl l' ti's /If C oy Truck_! `✓-e_ JAY'VI ce Ly Wit` d.T /"1.albslb /U keLL10 <br /> u� 2ticQ w� f es cyoP✓'oX rAkC fe DIV-p— <br /> uvea► � oiee.S Uie�tle <br /> for wo-s-fe �'Qwty✓a-P CuPIC� +;,,e-s 4 60- r'2-c (0-t_tl�s /v a <br /> a-�.p.eoQ <br /> V10 <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number I s ctor's ig ature Phone Number <br /> z .. 62081 <br /> INSTRUCTIONS ON BACK Correct 1nc�irrlact _ yl e Z 3 <br /> -- ...... <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />