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08262040569 <br /> == Waste Tire Survey & Inspection Report Inspection Report Number <br /> eae- <br /> .. srate of WMB11(Nea Survey Form - Page 1 I1 - 1088199 <br /> CIWMB 1B1(New 041041 Y <br /> CalHomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID. Inspection Type (Fill one) <br /> Site <br /> Site Suffix: LM: s S 19 © I ) ®Routine Q Re-inspection Q Referral Q Observation <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier. SA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �-M–cZ 's_� pse,_LNc_ <br /> Physical Addre—is <br /> �31_3_Z-1=,ate► - — I <br /> Street <br /> Inspection Data <br /> City � Srarc /_1P Coda Time In Time Out I <br /> Business Rep Title —� ` O AM I 1 O AM <br /> �•I� —Li O PM j'1— __ O PM <br /> �olti tis_StR.k_Lb_ - __A_ . t_r.__. <br /> Operational Status Tire Type Business Role Storage Type' <br /> Tire Count(Whole/PTE) TT (Fill one only) '(Fill all that apply) (Fill all that apply) (Fill•all that apply) <br /> �'.2 V 0 Active 0 Passenger 0 Generator •Outdoor <br /> O Q Closed ®Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - --_ Q Inactive Truck <br /> O <br /> Longitude _ Q Planned •OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet p Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder i Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORC-EMENT <br /> V �,HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Uiolatlon Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance 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-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or[YT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C-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 11111111In Compliance - No Violations <br /> 0,0 Other: §§ <br /> Comments Jeo—//f Ave i N Ap��i A� d1't /�.iw _,G—. /.Oti�r%v� c.1ay Nil r�aY <br /> '_��.�y y a/1ti�10� )�<e a..-R_ O.•� <br /> -s �r_t JJ - � os (/�dF C}or S_s�� • ��et�o 1/yd3�3 e'L <br /> C2_t��o f•-�- . <br /> zm <br /> Inspection Form Included:Q <br /> Comments Included:Q — - - _�^��L4-G <br /> a 6-+3 <br /> Business Rep's S gna re hone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrec: 62081 <br /> • ExAM -P �LE 1 '2S <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />