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08227040103 <br /> Waste Tire Survey.& Inspection Report ... Inspection Report Number . �. <br /> State of CalMarn'a' <br /> grated a(tleMaage Survey Form - Page 1 19 - 1 01 0 8 8 9 <br /> Califomla Integrated Waste Management Boartl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- 11 ^ y/ D Inspection Type(Fill one) <br /> Slte suffix: / (� 0 Routine Q'Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier:IdentJr� Q CHP Q CIWMB Q Complaint Q-Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector. <br /> 1"04 2y�A .t 1 3 9 — / 017/ L?�f <br /> Physical Address <br /> Street <br /> Inspection Date V <br /> 5T C4 4520 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> t +�� �A/ 0. MO/Ch(� ,�QL.JNiLQ •m 0 PM m•m O PM <br /> Operational Status Tire Type .Business Role Storage Type <br /> Tire Count(W hole/PTE)U r I I I i f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active •Passenger O Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude . Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer _ i Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 <br /> - I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> VM HAULING AND MANIFEST REQUIREMENTS <br /> Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q <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(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 0. 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 /> 1010 Other: § <br /> Comments <br /> !'�v7�-� i�s�t�c-�l�r_,�%7_.tiw�a.��__-J�t�_/�r_l�owJ_:nf-;►-Wa.a-.tLd.T1..9:_ <br /> c.iz.2-0 at.a..p �' 'Lt!as-w_o�K.%f 'a�l�/'1�C.-.-�`J /��-lTas.�,-c-•- <br /> CzO' <br /> Inspection Form Included:Q } � 46g <br /> Comments Included:Q� AA�, <br /> Business Rep• ignature Phone Number Inspector's Signature phone mbar <br /> 62081 <br /> INSTRUCTIONS ON BACK Co � ' Incorrect: E X A M4 P L E 1 2 3 <br /> ■ White Copy.CIW 11Yellow Copy Operator Pink Copy:LEA ® ■ <br />