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98227040L87 <br /> Waste Tire Survey & Inspection.Report. Inspection R?Port Number. :' ■ <br /> r� Stab ar calNomla <br /> CIWM8161(Ne 04fe4) Survey Form -Page 1 '1 6 - 1 01 0 8 7 8 <br /> ' Calllomb InbprataA Waab Management eoaN <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / O - D / Inspection Type (Fill one) <br /> Site suffix: r 40 Routine O Re-inspection O Referral O Observation <br /> LocalH Referral,choose referral type(Fill one) <br /> Identifier: SA,.I 'a-1 . .,r:..f . �pv L7%_, O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility-Name IJ 1 <br /> Inspected By Inspector <br /> CLicl/t9� <br /> ( T/1 �� 1 [?> d — <br /> Physical Address I - <br /> 3 Y0O �Ta 8�2A IAA4t_j <br /> Street 1I / / O <br /> Inspection Date <br /> city �— JZ State ZIP Code Time In Time Out <br /> fry <br /> Business Rep Title F_]_jO AM O AM <br /> /I�LE�1G-A�� O PM m O PM <br /> 1 L1 „ VrGE —.. <br /> Operational Status-Tire Type Business 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 /> _j r t_-1.J—J r 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O O Closed O Altered <br /> GPS Latitude m• O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude - FT-1-1O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler ' O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body 0 Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other I <br /> Part B•Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF.ORCEME NT STATUS <br /> V A HAULMIFETIEMENTGD S <br /> (�Notice Of Violation O Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2:1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O . 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462:Manifest System Requirements for Tire Dealers or Waste Tire.Generators •In Compliance - No Violations <br /> O O Other: § <br /> Comments DR �� <br /> /� —dot—/ �Ea'�' W_•y�.�s_t►a.�, <br /> �iQc� t�w�- ���TiH.��1 �i/_,G/H�.w,o►�y►.� c�,o—T1t•c,.. <br /> r _ _i 44�jLt.� >!Y � ._/'?v_v _ _.L4 �c,r o..+�f,�as l•-.�� 2 <br /> —�,, 1 til BC��D _ —Ot> � s_<<�!._�G L/ Arrov�S_O.R— trchS All rLa� <br /> Inspection Form Included:O <br /> Comments Included:O— B 903 <br /> Business ie s ature Phone Number' Inspector's Signature Phone--- <br /> 6 <br /> 62081 <br /> INSTRUCTIONS ON BACK7C, <br /> correct: X A M P L E - 2 3 <br /> . WhiteYellow Copy.Operator Pink Copy.LEA <br />