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1 <br /> Inspection Report Number <br /> Waste Tire Survey & Inspection ReportState ■ <br /> CiWM of California Survey Form - Page 1 14 - 0 2 5 $ 6 6 <br /> Cgrated 1(t eManage) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details J <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix; 2. LF 6 j - 0 Routine O Re-inspection O Referral O Observation <br /> Local �-, If Referral,choose referral type(Fill one) <br /> Identifier: �cr ��� af. ^,�y �N11 O CHP O CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name �J <br /> Inspected By Inspector <br /> Physical Address - C-> 1 �r.t G .t44,s <br /> f 735 Lam' Lac. -rQ j Lad; <br /> Inspection Date Q / Cl) <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> /+ �} O PM O PM <br /> Y Operational Status; Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f Q <br /> ®Active 0 Passenger ®Generator Q Outdoor <br /> 0 O Closed O Altered <br /> GPS Latitude O Hauler i Indoor <br /> O Q Inactive O Truck <br /> Longitude - O End-Use Q Container <br /> O Planned Q OTR <br /> I <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder ®Otherzrl, (� <br /> t- <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility .ENFORCEMENT STATUS <br /> ►`f <br /> HAULING-A04-0 <br /> 0001111TANQUIROMONT <br /> O O O Notles Of-Violation (9 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ( Dat9 !�l / S' Q S' <br /> O • 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requ1mcf fW NOV or E)T) <br /> O O .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 }P5tIf1'M r'j 'Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r <br /> O O Other: § -- <br /> Comments 566— �'fC7 C���✓�165, 4 f.�fJcQ•cT<� ^� � - <br /> acPr,Z►-mss -a( . )ZxsP <br /> wG c� -ice Zwt�is 4-o +ll61, (,,,,�tgtt:r 1;'1333 �w <br /> f4, t.,,.r-c.. t„ S�r. -f;r'e �a <br /> Inspection Form Included: t� �"� <br /> included: ���'7 �j� <br /> Comments O uses eIgnature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK �.t+AErlf#� r °If1i` � �" 1 'CE _:�+r! !�� 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />