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08227040103 <br /> Waste Tire Survey & Inspection Report • Inspection Report Number <br /> roe- I 1 - 1088112 <br /> a; State of Calltomla - Survey-Form - Page 1 <br /> CIWMB tet(to Management <br /> g <br /> Calltomla Intagreted Waste Management Boats `� <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPIp <br /> Sit , 1. / Inspection Type (Fill one) <br /> e Suffix: 11� / •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �A�� �. � O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By � Inspector <br /> I C�/Efts �a I Pmt C-asv�p0 r T=.s-s�i3�✓ I 'J - I ( I <br /> Physical Address q I�� I HA 4-P —_—I <br /> I Street0, <br /> Inspection Date <br /> C—Tice�., C.+ 9 530�_ _ <br /> Clh/ State Z!P Cu�r.J Time In Time Out <br /> Business Rep Title O AM �- 7 I� O AM <br /> -- ( ' O PM <br /> O PM <br /> Operational Status Tire Type Business <br /> Role Storage Type <br /> Tire Count(Whole/PTE) e� (Fill one only) (Fill all4hat apply) (Fill all that apply) (Fill all that apply) <br /> L 0 Active Q Passenger *Generator 0 Outdoor <br /> - - O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive •Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair .•Trucking Fleet Q Government • Q Retreader Q Dismantler Q Tire Derived Fuel <br /> i <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 t <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation <br /> O O Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. @ompliance t)eadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 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 /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> O 10 Other: <br /> Comments . / o _�1_`! t9t.J f <br /> S ►!� �e , ✓:ja/.�-7'�;0"r * yr �fL'a+� Ga..c►=►_s�/a�&eQ, <br /> 2aQ <br /> Inspection Form Included:Q <br /> 'Comments Included: <br /> Q Business Reps Si ure Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co reef: I correct: M P L 1 2 3 <br /> ■ White Co .CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />