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z <br /> $157040116 <br /> 0 Waste Tire Survey.& Inspection Report Inspection Report Number <br /> Btab MB of Calita <br /> 181(NmfaewOdled( Survey Form - Page 1 1 6 10 7 9 2 2 9 <br /> CMI <br /> Calitomia Inlegreletl Wasta Management Boats <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 9 12R' I ! [R- <br /> Q Routine Q Re-inspection Q Referral 0 Observation <br /> Local C If Referral,choose referral type.(Fill one) <br /> Identifier: u,4fj J i1 dam. N � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1_ 7�ra,vs i d9c�,►��✓ 13 c� - I i <br /> Physical Address Jia""( <br /> L=- Y.99 <br /> Street <br /> L 95245 1 Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> m' 0P m'm 0PM <br /> -. --— Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r i I � I <br /> Q Active Q Passenger Q Generator Q Outdoor . <br /> Q Closed Q Altered <br /> GPI S Latitude I I HO Q Hauler Q Indoor <br /> •I -L—-� 0 Inactive .Truck <br /> Longitude ._ .I I I I - I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) J 111 <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 /> I Q Service Station Q Hauler Q Agriculture Q Shredder. Other L� rl u,p-pt[TAi/fir�/G.S <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A M1111AULING AND MANIFEST REQUIREMENTS <br /> xtension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violatio Q E <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 <br /> Q Q 14 CCR§18459.1-Tire Program 10 Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FJCTJ <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/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 1 Q 1 Other: § <br /> CommentsQ���fiG^/ /tel ` O'h %l1r.S <br /> —�,�1 �'—r-A1C---��iFO.il/_aWr�NQ—ff'A4S 11ME!a <br /> s_�o�a_�:�l,r�,�;_.ra_cs CSF a��T�rG W ovLlc is�c`�oss�._tom fiic.�'•— <br /> _S :nret5 eAG.�• a J,y/ oralsOQ "'s �OT . <br /> Inspection Form Include�-o44.q Comments Inclu <br /> Ws4WM4. -— 9`} <br /> Ws n to Phone Number Inspector's Signature Phone Number <br /> i)"INSTRUCTIONS ON BAC orrec: PIER, ct: E X A Ah P 'Li, 1 ;2 3 62081 <br /> ■ <br /> hit <br /> e opy CIW Yellow Copy Operator Pink Copy.LFA <br />