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�ocav��tuaU� <br /> Waste Tire Su -y & Inspection Reporr. Inspection Report Number <br /> row State of California I 1 - 1.08692 2 <br /> Cgrated 11steManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board — <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- La <br /> � - Ell <br /> Inspection Type (Fill one) <br /> Site Suffix: L, L14 <br /> S n 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local v` If Referral,choose referral type(Fill one) <br /> Identifier: Sao Zola. t 1 n �((� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l�—'tet -1 Inspected By Inspector <br /> Physical Address ' 3 i 10 <br /> L_a%b_ _T_A,j.ca - <br /> Street <br /> C�' QS�oL I Inspection Date 1l7_ J <br /> city �- v� Time In Time Out _ <br /> City State LIF Code <br /> Business Rep Title I O AM [7 : <br /> jI 5� O AM <br /> PM <br /> — - C�Qcde, ---- y - -._ <br /> .f .Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) •I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)O '� ® Active Q Passenger 0 Generator ®Outdoor <br /> 10 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <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 Q Other I 1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility RENFORGEMENI STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 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 EXTJ <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!C-IWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use.Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q 1 Other: <br /> Comments I t <br /> `J_Wn5 <br /> Inspection Form Incl de <br /> Comments Included: <br /> Bu in Signature Phone Number nspect s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor a I nn..loo.r, IEIXIAIMIPILIEI1112 3 <br /> White Copy CIW B Yellow Copy Operator Pink Copy:LEA <br />