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4,,H4 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> IN SgMB Calmia Survey Form - Page 1 I 1 1 188419 <br /> ('i111 161Ffo(New e41a4J Y <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey" BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type(Fill one) <br /> Site Suf x: ` V 6 Z 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L�ya U� .2 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i <br /> Qu_AddAddre =1 <br /> re 7 ° ' - (arLtio_A_rarrtbv J <br /> Phys cal <br /> I a-7LtC1_FL Dom\ <br /> Street Q / / <br /> Inspection Date V <br /> �Sk06, 1k0_n CC-11- a5"0 -1 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title ` O AM' O AM <br /> 1 ®PM O e PM <br /> Qe�cfl_Meiere� 5d. ®umef — -- <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 /> r r ` 0 Active ®Passenger QA Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauier Q Indoor <br /> -_, _ _-. .-_ - _ _ -o Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use 1 Q Container <br /> I <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 /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V l A I 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-RegistrationlDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EXl) <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/CIWMB 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 QOther. g <br /> Comments InA,\ N��r & , A�io )'�,P_lenr r_z <br /> son A�f�cN� olile {�� �1a5 Ken Over <br /> Oil�� Y i. I T / <br /> Inspection Form Included:Q � / � <br /> Comments Included: <br /> usiness Rep's Signature Phone Number Insp c or's Si§n ure . Phone Number <br /> �-,( 62081. <br /> INSTRUCTIONS ON BACK orrect: Yf <br /> correct: (� rJ X a M P L <br /> ■ White Copy:•CIwM Yellow Copy:Operator Pink Copy.LEA ,. ® ■ <br />