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OSd66040046 <br /> Waste Tire Survey & Inspection ReportInspection Report Number ■ <br /> rr <br /> CIWMB <br /> 181(N.. - Survey Form - Page 1. 15 - 10 7 9 4 5 0 <br /> GWMB 781 sNaw 06!06) <br /> Calilomie Integrated Waste Management board <br /> 'art A-Survev. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> f TPID- ,T - Inspection Type (Fill one) <br /> Site Suffix: ' 13 S 9 p ,� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r_--�_ If Referral,choose referral type(Fill one) <br /> Identifier: I c ql�y,,.� Cyvw�,, I 0 CHP . 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name�. L <br /> Inspected By Inspector. <br /> LPhysical A d_µc_ �r_t._�._,v12_►�l2 Se�^✓��C.a. I � - I / <br /> re 3 (, If <br /> L/-,��, <br /> Street <br /> Inspection Date <br /> t S'L3 / I v <br /> City CASla e ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> MOPM F T1aPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Court (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t(W of PTE) t I ,I S,G <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 1 f I I O 0 Closed 0 Altered <br /> GPS Latitude � ,L-1- I 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - I I I I l I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) 111 <br /> O 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 I <br /> Part B-Inspection.of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFORCEMENT STATUS____ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data 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/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 0 Other: § <br /> Comments <br /> CIT] ,sfi s v'�.� ��,e► ��I �tt. �1-�.. ��a k���. <br /> 11-7__ 61._F Jz L �vyt�y- —2✓rs.pial!f rX�-AVIA-la— <br /> _,&r AVIA.,tie..—.&r —w v,3 0-g— 007Y4. /V� i�v l u f+vKs- t_a P 02F-Do il? aK <br /> Inspection Form Included:01 \ <br /> Comments Included:Q <br /> Business Rep's Si ature Phone Number Inspector's Signature Phone Number <br /> c d I g I u I C I f 111213 1 62081 <br /> INSTRUCTIONS ON BACK <br /> Correct:* Incorrect: X A M P L E <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA �� ■ <br /> FILE COPY <br />