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030g9050027 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> - <br /> liY StatMB 181 <br /> 1Cali(New I 1 10 8 8 3.5 5 <br /> Crated asteMaage) Survey Form Page 1 j <br /> CaHromla Integrated Waste Management Board <br /> Part A.;U; ' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ p O n /_ O r Inspection Type (Fill one) <br /> Site Suffix: p( (� a lt! t ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (b ���� j1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ' Inspected By Inspector <br /> 1 _7-i'qc i f��@nomo� 1 3 - l o I L � <br /> Physical Addresyr <br /> I o?Sf7[)G Ckrisman <br /> Str <br /> h*T a et _, L 9S 3 Inspection Date <br /> City State Z!P Code <br /> Time In 1 Time Out <br /> Bu$lness R p. i TitleCn V D O ®AM ) 1 AM <br /> Oyn^ �aIS S L .!0PM (©• 0P <br /> _-IeA,c�C_��SW2ll 1 p/bfeGt'td�-i ; <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) -(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ®Passenger ®Generator Q Outdoor <br /> GPS Latitude II iO Q Closed Q Altered a Hauler Q indoor <br /> L - =-J• ----' Q Inactive Q Truck <br /> i <br /> I <br /> Longitude I Q End-Use j Container <br /> - 4 I Q Planned ®OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q ' Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q' <br /> 14 CCR§18459.2.1-SubmittalensLogs wdays <br /> of Comprehensive Trip ithin 90 d (Required for NOV or FXn <br /> _ <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 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 1 Other: § <br /> Comments — •h�rt,5�e��i on -H-v'.s Gkf,--. EH Sr X41 Fanso- mm bt t,lc,_-re sti,,t <br /> C6r, _ _ "r a e_s . Nor cds s j s - YI. kc Eos ell <br /> A 5 0. /� ctL'12h2,eh vJi.� 6Viroh imel lfara :60.14. 1._ r_ ;on <br /> mod ouk ead OF rh t acsz�;_S over <br /> Inspection Form Included:OF- "-c <br /> Comments Included:* <br /> ` �` 7 (D (Q <br /> Business Rep's Signature Phone Number Inspector Signature Phone Number <br /> INSTRUCTIONS ON BACK 1EjXjAjMjP1LjEj -111123 62081. <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ■ <br />