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I , <br /> 082.34040280 <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> Cr of CalHomla [ I 1 - 1088150 <br /> gWMa,l,stleM-9 Survey Form-- Page 1 <br /> CaliTomia Integrated Waste Management eoard <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Typo (Fill one) <br /> Site Suffix: / 3 _I � I - Loll] <br /> Routine Q Re-Inspection Q Referral Q Observation � <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: X44 SCo T i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /f v p y <br /> Inspected B Inspector <br /> Ph�i Aae _ -a. ....�or►�r c T-eic.J 3 9 _ L/J() l aAE- <br /> Street Inspection Date D lo <br /> srbd-"' 9 5V3 <br /> City State ZIP Cor'eJ �Time In r Time Out <br /> Business Rep Title _I I 1 f -1 O AM I—I -� -� Q AM <br /> L0 PM <br /> TIM a r<T6 _ ._.: ur• -, ---- <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) R (Fill one only) (Fill all that apply) (Filial)that apply) (Fill'altthat apply) <br /> t ' L Q Active Q Passenger .0 Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -O •Inactive 40 Truck <br /> Longitude r- I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill Al that apply). <br /> Q New Tire Dealer. Q Auto Repair Q 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 0 Other Ita✓_ K -} <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility _E FO C- MENT S A US <br /> V A A LING A MANIFES REQUIREMENT <br /> Q Notice Of Violation 0 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 /> 00 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§10459 -Responsible Entities Complying with Manifesting Requirements Date m <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 DC7) <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/ -IWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> Q Q I Other: § <br /> Comments AJ <br /> _/�i,v>�et•�.aR,�fa8.ta.� �a..�� Wu4.�.Q—�•rt G=a.�Ui� .9��C.�✓ 6//.3/_�iJOS_._ <br /> Inspection Form Included:Q <br /> Comments Included:Q- - <br /> B iness Rep'sl lure Phone Number Inspectors Signature - Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI1 2 3 62061 <br /> . White Cop CIWM Yellow Copy Operator Pink Copy:LEA ® ■ <br /> J <br />