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08325040034 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stae <br /> CIWMtaof1e,Call(ornla(Haw U4r04) Survey Form - Page 1 1 - Il - 1088028 <br /> Cali,omia Integratatl Waste Management aoaro <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> — <br /> TPID- i I Inspection Type (Fill one) <br /> Site Suffix: ' �2,i 5 13I I Z- Q I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local c,, ter- 1 If Referral,choose referral type(Fill one) <br /> Identifier: an .J batt Gl I n C O uT*y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> � l?30 's Pr_ec�s.i_on—A.t�r!'o__Gertfier_� mo� 3i—' i <br /> Physical A�dress <br /> LS <br /> 1 - Q I Kf-ISt 4n L(lC C15 1 <br /> __j- — <br /> Sry r Inspection Date I r T I <br /> (1�t cA X52 o I o / �z__z ; I 0'8 <br /> Gti— y-' — --- -- - Stain !1,'° ..: Time In Time Out - <br /> Business Rep L Title — ^O AM --' I 0 AM <br /> Bob . Batrbee- f�Y12.r O PM - O PM <br /> V 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 *Active i Passenger *.Generator IS Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer to 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal 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 forNOV or DCT) <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 1 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 10 1 Other: § <br /> Comments <br /> Raufi�f,Q._�nsp�`i_'►.o_��.r�ocf�,ed t4,:t�dcs�e$�h��a1.1_o_l�wss�af P-d <br /> cece t been Irermvec4. enc Lt vses�a.�ttlla-Ct�D_isQo�uL r <br /> QSt. t�e_c�rrLvci1�—C'21�cnAests�uev�e�hloe�scf c�ern <br /> Inspection Form Included: (20', <br /> Comments Included:Q Business Rep's Signa-fu—re Phone Number In a ors Signature _ Phone Numbs r <br /> � 62081 <br /> INSTRUCTIONS ON BACK orrect: I correct: X A MTPL E 1 2 3 <br /> . White opy.CI Yellow Copy.Operator Pink Copy.LFA ® ■ <br />