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07235050004 ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ _, 8 - 1 0105 17 <br /> 11 Stat of Gll/ornVa <br /> CIWMB 1 at lNn.04M4) Survey Form - Page <br /> Cauromia Int.grat.d Waw Manayemant Board BLUE OR BLACK INK PEN <br /> Part A_Survey — Inspection Dot Its _ T <br /> Business Profile <br /> (j Inspection Type (Fill one) <br /> Site Suffix: ®Routine 0 Re-inspection Q Referral Q Observation <br /> If Referral,choose referral type(Fill one) - <br /> Local (' CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> 1 identifier: -�O (� Q - <br /> Business or Facility Name Inspected By Inspector <br /> 7—MA F TZ <br /> l—_�_ <br /> zE - F il L <br /> Physical Add 1 _ <br /> �I S Ca�m' - S�='I <br /> Srreef -�7y�/_ /�j� I inspection Date <br /> 9��0� Time In Time Out 1 <br /> I�f -Olia i IP Code <br /> City I AMTi I � Q AM <br /> Business Rep Titlem:[:EO <br /> PM _t- O PM <br /> I{ �� c[/r ✓ t —� Business Role Storage Type <br /> operational Status The Type I Fill all that apply)' <br /> (Fill one only) (Fill all that aPPh)I (Fill all that app Y) <br /> Tire Count(Whole/PTE) it ®Active ` Q Passenger Generator Q Outdoor <br /> i0i � Q Closed Q Altered 0 Hauler QIndoor <br /> lie <br /> PS Latitude <br /> . <br /> GQ inactive Truck <br /> ` - — - F—,o IQ End-Use I O Container <br /> 1 Longitude - I Q Planned ®OT <br /> B <br /> usiness Type (Fill all that apply) _ Retreader Q Dismantler Q Tire Derived Fuel <br /> Neal Tire Dealer Q Auto Repair ®Trucking Fleet <br /> Q Government Q <br /> Used- <br /> Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ®Hauler Q Agriculture Q <br /> Shredder Q Other <br /> - <br /> Part B-Inspection of Waste Tire Deafer,Generator,Hauler and End-Use Facility ._ENFORCEME._.NT�--STATUS --- — <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> QQ PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> IQ Q I Compliance Deadline <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q I Q PRC§42956-RegislrationiDecal in Vehicle I <br /> 010 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> IQ Q 1I14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB I` ^(Required for NOV or IXn-' <br /> IIQ Q 1 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 9 s days i <br /> 10 I Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years Q Referred f CIWMB Enforcement <br /> IQ Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers - <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> `Q I Q gOth <br /> §18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> (� § — - <br /> iComments D,,,,.�`_ __ f<A (S <br /> Vim" - .015 amr--pa , e��yoSS e ►- i <br /> s r la w(- �e Pv MA do sus - <br /> �a ._C7-L�zyler� -:-�---- <br /> Inspection Form Included:Q, <br /> Cts In pt/ors g ature Phone Number <br /> Comments Included: Busi Si Rep's S gna Phone Number __ - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Inc rrect:R V E X A M P L E <br /> iZ3 ® ■ <br /> ■ <br /> While Copy CIWMB Yeibw Copy:Operator Pink COPY IEA <br />