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�f9��309��43 <br /> Waste Tire Survey 0 & Inspection Report Inspection Report Number <br /> 0 <br /> sr,e o,1al(Ne l 9 � 1088340 <br /> CIwMe,aa310 a4,gE) SurveyForm - Page 1 <br /> Calllomla IntegrateA Waste Managemene 9oaN <br /> Part A-Surye BLUE OR R BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site Suffix: - ® <br /> TIMID- Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � V N Referral,choose referral type(Fill one) <br /> Identifier: w 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or'Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> Cit;' t��-1— 453.20 <br /> GN S'rate Z!?Ccd� Time In Time Out <br /> Business Rep Title <br /> -- — - ®AM —- —�- --- <br /> O AM <br /> 0OPM QOPM6a Lan_ --- - Mav\U C - --IOp�retiIStatus Tire Type <br /> Business Role Storage Type <br /> Tire'COunt(Whole/PTE) / '(Fill one only) .(Fill all that apply) -(Fill all that apply) (Fill all that apply) <br /> t7 O' 0 Active Passenger ®Generator 0 Outdoor <br /> .O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler (a Indoor <br /> .. 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 <br /> 0 O Q Notice Of Violation Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2:1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities -- <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 10 1 Other. § <br /> Comment�sp N, <br /> ('�X"lt.\� <br /> oc' <br /> Sec—�r C /�o_v V> �i��S�I- <br /> -- -Inspection Form Included:0 '�—ZZ-13 <br /> Comments Included: 0 eke—p", <br /> - <br /> Busine Si ature 'Phone Number Inspector's Signa re Phone Number- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X I0 E X A M P L E 1 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy LEA © ■ <br />