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_ VOCO64'�1V�0 V <br /> U!, Inspection Report Number <br /> Tire Surve & Ins ection Re ■ <br /> srwMe18lfuma Su <br /> rve Form - Page 1 I1 - 1088252 <br /> CmMB 1t11(New gu011. <br /> California Integrated Waste Management Baartl <br /> 'art A-SurveY BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f O 1 n I I Inspection Type (Fill one) <br /> Site Suffix: I I I 11 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /f If Referral,choose referral type(Fill one) <br /> Identifier: �AN �Ogqu,..einl Lp0.0v y- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ,VV, Q �J Inspected By Inspector <br /> �i�ac,rs b1 e-5�1 r'✓ICG I _ <br /> Physical Address I L I b <br /> �I� I � L�.9•ct_I'I�_A�D��1� <br /> 12473 Loo,.,:s �l I <br /> Street <br /> a��, ^L ��� Inspection Date <br /> 57O (XJ L 9 V fC�J <br /> C J■ s. � <br /> City State ZIP Ccc'_o Time In _ _ Tlme Out _ <br /> Business Rep Title r—h , �— i0 AM 1 Q AM <br /> - 0 PM I L_ 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only)' (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ! _ 0 Hauler 0 Indoor <br /> Inactive Truck <br /> - - - D <br /> End-Use Container <br /> Longitude - ! 0 Planned 0 OTR 0 0 <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> L0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other t ,5 Ri�q I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility S <br /> AULIN_G A-%IMANIF.EMIREQUIREM ENi <br /> 0 00 Not ce Of Violation n Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance lea line <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / MEN <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days Required for NOV or <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Refereed 1 C-IWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance No Violations <br /> 0 0 Other: § <br /> Comments i <br /> �_ _. _��—�0_Ed�✓_t q0 eu,v�_7�%LC-1.71 ��-G..�.�/ {y%e <br /> Ae <br /> --A. -V_fe <br /> Inspection Form Included:0 ! F�tlr, <br /> CommeBusiness Rep' Signature Phone Number Signature Phone Number <br /> INSTRUCTIONS ON BACK "TRUMV,11 correct: ���X�aIN►�PIL�� �12I3I 62081 <br /> White Yellow Copy.Operator Pink Copy.LEA ■ <br /> I <br />