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08262t14CS58 <br /> Waste Tire Survey & Inspection Report Inspection Report NumberStal ■ <br /> CIWM rC11.ON W SurveyForm - Page 1E171--- 1088253 <br /> CIWMB 1a1(New 1W041 <br /> Calitomla Int?W.d Waste Management 6oaM <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: I / 3 } 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> au-s-I n-a s S or Facility Name - ----- -- <br /> Inspected By Inspector <br /> —'li- rCY A s ��■ <br /> Physical AddressI ��14t1t r-y���VJ <br /> i <br /> Street D /� <br /> Inspection te 7 <br /> ion Da <br /> 1 J I i <br /> C,ty G - C� ctj,, sZip C6ije �Time In Time Out _ <br /> 1 <br /> Business Rep Title Q AM Q AM 1 I 1,i , <br /> ` - I 0 PM _�'I J QPM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger •Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude ! 0 Hauler 0 Indoor <br /> -- <br /> -- - 0 0 Inactive 0 Truck <br /> Longitude 0 Planned OTR 0 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 Relreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility NFORC-EME_N___ ST TUS_ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Regislration)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 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required torNOV 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 n Compliance - No Violations <br /> 0 1 0 Other: <br /> Comments ��`*Ya.'�'7%VZ •'n!S r'�1•�_0✓t '/Ze+•nn0 CCw 4i-��.��/t}e�'OLa/it�/� LJQ4 <br /> _t�0�%iu��,'e•rc�_ate �-a� C..-t_n_s �0_7'�-Q. <br /> Inspection Form Included:0 <br /> Comments Included:0 - - 63 <br /> �Bu uriess Rep' ignature .Phone Number Inspector s Signature ro mnber <br /> INSTRUCTIONS ON BACK 10XIAIMIPILIE1 1112131 62081- <br /> ■ White C py CIW Yellow Copy:operator Pink Copy:LEA ® ■ <br />