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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CrWM 181lNewCairforniI Survey Form - Page 1 ! 1 7 - 1 0 7 3 3 7 2� <br /> CRNMB 181 New 04101 <br /> Calllomla Integrated Waste Management Board - - - <br /> Part A-Su; BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / I I y /, I I Inspection Type (Fill one) <br /> Site Suffix: _ I I_!I_ O � �_J i / S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �0 {� _� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> -- -oro_t---- Corts4C"_Cf <br /> Physical Address t`t�' _ � 3� - Ir o i�J^�� <br /> Inspection Date <br /> City —� Slate Zi?code. Time In ____ Time Out <br /> Business Rep Title O AM EEO AM <br /> D ��✓ � �QY'Q Y1'lG(h, [7- <br /> - O PM — O PM <br /> Operational Status Tire Type - Business Role Storage Type <br /> Tire Count(Whole/PTE) hy( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r' r V/ ®Passenger Q Generator Q Outdoor <br /> Q Q Altered <br /> GPS Latitude Q Hauler Q Indoor, <br /> �400 Inactive ®Truck <br /> Longitude - i I Q Planned Q OTR Q End-Use Q Container <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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q IQ PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle n� <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W 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 EXT) <br /> O O <br /> 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 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 Q Other: <br /> § <br /> Comments 1�/_�S .1�,->(p -� ;5 .� r�)- .�..(i.,c- ve/_ <br /> iw C __(IIlIAj 1 r- - Vt�l (nein—✓7�`- O�tc Q to _�4�+rry A n C��/ <br /> C f -k <br /> ,e�uic:2 a ,/ti clan N o rn --— _cg e`-tir'e �aS_ <br /> N22d2c�_ C7ls Vim-. eCon�r in <br /> Inspection Form Included:Q <br /> Comments Included:Q-a- ds <br /> - — - - �P�2n�NuOW� b <br /> s ep r ureer Inspec 's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: ( E X _ArAk P L E1 111213 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />