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08010040194 <br /> Waste Tire Survey & Inspection Report InsPectionReport Number <br /> State of California <br /> Cgrated asteM nage Survey Form e- Page 1 I Z - �1 0 7 3 5 9 9 <br /> California Integrated Waste Management Boats <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> ( TPID- Inspection Type (Fill one) <br /> I <br /> Site Suffix: 3 y :7 b / S 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: . Ls_� --tpe14�.,,. Com. ,_k, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J U Inspected By Inspector <br /> Physical Address 3 — L/L---„-�,.- D_ � J <br /> � <br /> Street <br /> �1�37�� � • �tnn�IZd I ____ �T�^"�."!7°��-"T�-- <br /> Inspection Date. <br /> City I Q State3 ode Time In Time Out <br /> Business Rep Title m <br /> mopm m m o PM <br /> _ Operational Status Tire TypeBusiness.Role Storage Type <br /> Tire Count(Whole/PTE) I�j{ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0Active Q Passenger Q Generator Q.Outdoor <br /> � � <br /> 1 <br /> GPS Latitude W,� 10 <br /> Q Closed Q Altered Q Hauler Q Indoor <br /> f I o Q Inactive 0 Truck <br /> Longitude — 1 J I I Q Planned 0 OTR Q End-Use Q Container <br /> Business Type.(Fill all that apply) l <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ,( ( STATUS <br /> VSA. LHAULING1AN04MANIFES1TiREAUWREMENTiS <br /> Q Notice Of Violation (�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. Comi�Iianee Deadline <br /> 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 EXT] <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§16462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance No Violations <br /> Q Q Other: §, <br /> Comments p� <br /> 1n1)l�rnc.—�f 1-iYz-, I�rl:a�a/��—r-t:�-�•�.e-cf—�v�iu-r_l�e�Zf- <br /> _m_t_L_s1-� rt�cst.-) -T•ts ,w.��x•_._s�rcnr.�—m�_t�.'t_c_.—N�f�-iu c�h�vvY•�c.�.- <br /> f�.i,1�o� Mcperfztm—T/n vl�ltunovtr <br /> Inspection Form Included:0I0 (W) <br /> Q1 /1 1 X.- 83�4(,o`7 <br /> Comments Included: <br /> Business �s,$ignature Phone Number Inspector's Siig ure Phone Number <br /> INSTRUCTIONS <br /> Included:NSTRUCTIONS ON BACK Correct: Incorrect: I EIXIAIMI P I L I EIItI 1 1,2I 3I 62081 <br /> ■ While Copy:CIWMB Yellow Copy.Operator Pink Copy LEA ®' ■ <br /> �I <br />