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uo�oc�y¢ia-nem <br /> •iec- <br /> Waste Tire Survey & Inspection Report Inspection Report Number` <br /> O;W State of C.,Iftr­ <br /> CFWMB <br /> grated astewaage Survey Form - Page 1 1 9 - 1 0 7 9 3 1 4 <br /> Calltomla Integrated waste Management Boats <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile inspection Details. <br /> I TPID- Inspect Type (Fill one) <br /> Site Suffix: [j�Kp 76 J ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: AQ�.C(j1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical AddMss13 I ��t�g/3 cr /J"�Z/ <br /> �J I <br /> -� J��_ <br /> Street <br /> r It 9 Inspection Date <br /> I � 9S�o61 <br /> Citytatetate Z� Time In Time Out <br /> Business Rep Title1&� <br /> AM / ®AM <br /> I� O PM � O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply), (Fill all that apply) <br /> Tire Count(Whole/PTE) I t <br /> I Q Active Q Passenger Q Generator Q Outdoor <br /> I . I O Q Closed Q Altered <br /> Latitude <br /> GP$ �J, Q Hauler Q Indoor <br /> ( O ®Inactive Q Truck <br /> g <br /> Lon itude — ��l Q Planned Q OTR Q End-Use Q Container <br /> :11 <br /> Business Type (Fill all.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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS _ Q Notice Of Violation Q 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 /> PRC§42956-Registration/Decal in Vehicle . <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date El / <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 FF>CT) <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 I C-IW MB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ae;-&v q Kp r,epD Or•�p`�C +C�_A �( �Q��� <br /> a,2Q q%re woos-�C pllo.�e QyG�Qx"` a� a,� Alr`Al, <br /> terry re w1 zvc Q AfA -Aelir <br /> &Q,/ A-ey, -al o... rw,4 14L 3 vee rs. <br /> -- <br /> inspection Form Included:QXA <br /> � <br /> Comments Included:Q, . <br /> usiness Rep's Signature Phone.Number. Inspector's Signature. _-Phone;N"umber <br /> - INSTRUCTIONS ON BACK Correet:� Incorrect: E 1XIAMI P ;L E, <br /> -I j2 131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />