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073190410164 <br /> N IWastee:Tire Survey.&'Inspection Report Int;pet ion Report Number <br /> CIWMB 181 IN-04104) ' Survey Form- Page 1 .-- - .1 9 . 1 0 7 3 5 8 0 <br /> California Integrated Waste Management Ban' <br /> rd <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID- / ? C/ Inspection Type (Fill one) <br /> Site Suffix: / 3 5 q ✓ / 0 Routine 0 Re-inspection 0:Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:.. �cW1 �ar,L.i v� C�.wta Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name,J V Inspected By. Inspector <br /> . <br /> "Lis <br /> cac;1_rti _. <br /> Physical Adds vty� I <br /> o � LA_ <br /> l <br /> Street <br /> Inspection Date <br /> A <br /> C 16 Z2_,0 _j <br /> City I State ZIP Code Time In Time Out <br /> Business Rep Tidce�l <br /> is PM ED m s PM <br /> L_.F.J'cl tM4r I-I-'('-iks I I._D.V.1�_f"Of eyY�OcN��i <br /> Operational Status Tire-Type. Business Role . Storege Type - <br /> (( (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active Q Passenger. 0 Generator 0 Outdoor <br /> �I 0 0 Closed Q Altered <br /> GPS Latitude W.1-7 T-M Q Hauler 0 Indoor <br /> 0 0 Inactive ®Truck <br /> Longitude — 0 Planned 10 OTR 0 End-Use 0 Container <br /> Business Type (Fill.all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel ! <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other t I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use FacilityEN�ORC-____NT STATUS <br /> V A !HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 0 <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 <br /> (Required for NOV or EXT) <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 Referred/CIWMB 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 1 0 1 Other: §, <br /> Comments — <br /> {�1�(xc�r� rn� -{1,..s �.c>>-- u� -�/1lli.lSt�r-�in/a�-1-t rz-c�•�( <br /> _�'j� �• -��- -kaeu�d--LtPrlvl_ �t�ue-Cd -- q- _I irtt. olo�C+n/e��fJ� 1li'_Ql4► ivS_. <br /> Inspection Form Included:0 <br /> ab 2 <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS'ON BACK jE X a P J_ Ej 111,213 620e1 <br /> ■ While Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ ' <br />