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r <br /> 07354040054 <br /> Waste Tire Survey & Inspection Report - Inspection Report Number <br /> — <br /> "I state°1°aiir°` Survey Form - Page 1 16 - 10 73 4 8 <br /> MI7 <br /> CMB 781(New 04/04) <br /> Calitomla Integrated Waste Management Beard — —— <br /> Part A-Surve r BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I O Inspection Type(Fill one) <br /> Site Suffix: �� ®Routine Q Re-inspection Q Referral Q Observation <br /> Local N Referral,choose referral type(Fill one) <br /> Identifier: I spy _ — - Q CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name _ — Inspected By Inspector <br /> I <br /> Physical Address V L 9 L� ��3 ,}�•ty� <br /> Inspection Date <br /> Lac[: CA 9 g-2y o J L- <br /> Time In Time Out <br /> Business Rep Title I I I AM IT + AM <br /> APM <br /> 0 PM <br /> ' <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ' Q Active Q Passenger Q Generator Q.Outdoor <br /> o ®Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> O Q Inactive Q 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 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 (a 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 Q Notice Of Violation Q Extension <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs Within 90 days (Required for NOV or FXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O i 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O 1 O Other: § <br /> Comments <br /> �✓_�o-c�wu_.St�t�xw_.t!b{�-locxc�/. _�/�w,�.-n�-+nlx� ��s <br /> —q�-,c.�rh�c�f✓u-�ti���-��rrt��J Glo_s-w,� A �'���Gr/�grry-�r.�r�� - <br /> Inspection Form Included:Qom` <br /> Comments Included:Q ( �� 7 <br /> Business Rep's Signature Phone Number Inspector s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (� �Yj E X AJIMI P I L I El I <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />