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07312040464 <br /> Waste Tire Survey & Inspection Report Inspection Report Number 0 <br /> Q° gC�NY'°MB°`cal'r°rn181(New�Ob/ed) �/Surve Form - Page 1 13 - 10 7 3 5 4 2 1 <br /> ' <br /> Calkomla Integnited Waste Manapamant Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPe - o O O O — O / Inspection Type (Fill one) <br /> Site Suffix: / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -j'DQ�sLt..yt /,,.� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name \•% Q Inspected By Inspector <br /> Physicalress - 3 9 — / O / <br /> Street <br /> Inspection Date <br /> � S 3 o T <br /> GtL y / ✓ State ZIP Time In Time Out <br /> Business Rep Title m m 0 A m m O AM <br /> �y„�hro <br /> l(c.r a PM A PM <br /> v_ ma4vr-- -- <br /> --= Operational Status Tire Type Business Role Storage Type <br /> l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I r. I e r �S <br /> ®Active ®Passenger @ Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS .Latitude I H.I I ���� 0 Hauler ®Indoor <br /> i_ f 0 0 Inactive 0 Truck <br /> Longitude — I I�-1.I - I 0 planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ' 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body IF Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> VA HAULING AND MAN FEST REQUIREMENTS i0 Notice Wf Violation 0 Extension <br /> 0 0 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 (D 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days Required for NO 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 0 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 Vlolations <br /> 0 1 0 1 Other: §, <br /> Comments <br /> f�QwFttu..�t�e. _Zr,�4iev. �_—�'f dl�t.�.^_ /_,'�t_�Jtetn��e►r� /107GeLIK��r — <br /> —Qb—Si f-r IN�cGc fc /Xo_-►iiTcj�[�.x.�lc—�a�rSl,�P mt.�<I't.h.-,--+� r�'i-t.....u�...f"f <br /> c�as .,,—C=T-LsTYs��/ �°�'-,�-��t_--Gc_�/_T_/_Lf,s rc�rs/'✓+�/—�.. <br /> N�Y_c»l✓�,f+vx S , <br /> Inspection Form Included: C) <br /> Comments <br /> Busine s p's Signa hone Number nspector•s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rre Incorrect EXAMPLE 1 2 3 <br /> . White Cop.CIWM Yellow Copy.Operator Pink Copy LFA ® ■ <br />