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lWaste <br /> Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CWMa,at IN"04fe4) Survey Form - Page 1 1 5 ­ 10 1 3 6 4 0 <br /> California Integrated Waste Management Board <br /> Part ASurve — -BLUE OR(RI A KN K PEN <br /> Business Profile Inspection Details Q6194.Q•� p <br /> TPiD- �/ y D / inspection Type (Fill one) <br /> Site Suffix: / 0 Routine Q ReiQ nspection Q Referral Observation <br /> Local oose <br /> If Referral,chreferral type(Fill one) <br /> Identifier: t�2Gf�/H L.�/ittli � 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / a _ Inspected By Inspector <br /> W �a� lf'o t��tut2rtl�s i _ � <br /> Ph�ysical�Address -�cf/g.60%/L/F�V4 I <br /> 1 3737 W. Yog�-_ cyr_{, A-0- I <br /> sfrect / <br /> IGS�r a 95'330 Inspection Date Q 6 >✓ me� � 6 <br /> city late P OX Time In Time Out <br /> Business RepTitle I - le AM /0 � [: <br /> AM <br /> I O PM ` D O PM <br /> / p K LZLC <br /> — ° - - - 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) r , J ` <br /> Active o Passenger 0 Generator 40 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 1 O Hauler O Indoor <br /> - _ - 0 Q Inactive ( 10 Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> L_. <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires - <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)— <br /> t0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§16461-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 /> aLo Other: § ., <br /> Comments 124e� <br /> — <br /> o, : �a�r 2.-sic i r aud. 7�P�r . _F�d �'r��/ �o-C� �o <br /> mud�o S <br /> Inspection Form Included:0 A� <br /> / y <br /> Comments Included: <br /> Bus ss Rsep�'sSignaiture Phone Number Inspector's Signature Phone Number62081 <br /> INSTRUCTIONS N BACK orrect:; Incorrect: � EXAMPLE 1112 3 ® ■ <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy.LFA. <br />