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08024040133 <br /> Waste Tire Survey & Inspection Report inspection Report.NDmber <br /> State of Cetxomle Survey. Form - Page 1 18 - 1 0 7 9 4 2 0 <br /> CIWMB 781(New ONge <br /> CalMomia integrated Waste Manayemenl Beartl <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspe_ction Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: / 3 ! 3 S (7 y Q ®Routine Q Re inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: M —rycc ,,yt C ,� Q CHPQ CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Adhess L_�' Q n <br /> V 3---p <br /> - <br /> Street 3 <br /> - <br /> Inspection Date <br /> /6 / <br /> 'ES C_��� KS 10 i'State ZIP Coe Time In Time Out <br /> Business Rep Title ®AM 0 AM <br /> iI m O PM m m O PM <br /> —- —`— Operational Status Tire Type Business Role Storage Type <br /> ! <br /> Tire Count(Whole/PTE) r,/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � f(J <br /> r r 9 Active Q Passenger ®Generator ®Outdoor <br /> Latitude I I O O Closed Q Altered <br /> GPS J_I� Q Hauler Q indoor, <br /> �� �•�_ I <br /> _— —1-10 Q inactive ®Truck <br /> — <br /> Longitude - ...1__.... O Planned tQ OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Govemment Q ReVeader 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 Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator;Hauler and End-Use Facility ENFORC_E_MENT STATUS <br /> V A AULI G AN M 1 ES R6 IR. B <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O Q PRC§42953-Contracts With Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-RegistraliorVOecal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459-1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days ( squired for NOV or F,C7} <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 Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> -Ll-tCrte �Asn t1Y�'•�Tw�S GC7+�---Id�t� Y=is}��[1-at•NtI4Sl'i. �;tYS. <br /> —""►"'"�15—:m V;ctA }�ts+s—n .aas•! rzaemejot r,betc,k Apt3 <br /> Irr.% Si-r'rrr Lrw."-rv% j1R-f_YZ --�7^-YtXK—[ LAhco* <br /> Inspection Form Included:Q ' �}JU u67 q` L <br /> Comments included:Q— - <br /> Buslness Rep's Sig"nature, - .ti.:aP,honeyNumber - Inspector's Signature Phone Number_ <br /> INSTRUCTIONS ON BACK e c jEjXjAjMjPjLjEj 111213162081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />