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08157040084 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> y*qn olW..t.la Survey Form - Page 1 1 8 - 1 0 7 9 2 4 7 <br /> c1VYNB 187(New eAtD4) <br /> Callramla Intapnted WaaN Management BOerE <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- =.50 <br /> Inspection Type (Fill one) <br /> Site Suffix: r /PC / / QRoutine �Re-inspection QReferral <br /> Q Observation <br /> Localb If Referral,choose referral (Fill one) <br /> Identifier: <br /> C� � ��- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �l Inspected By Inspector <br /> L__ lam Ahem'c e p `-) <br /> Physical Address L3 / - O / �L( �+A,DtJy <br /> Street <br /> �SGala» G,¢ 95320 Inspection Date <br /> 1 O S 2 2 $ <br /> City Slate Zip code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 71 Q <br /> PM EEI: <br /> QPM <br /> l_>'9" J t cHS_A4/L.. -I Operational Status The Type Business Role Storage Type <br /> j <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fin all that apply) <br /> 1 � � l� <br /> Active Q Passenger ID Generator Q Outdoor <br /> ' _ �0 Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> + II{ I 0 Q inactive Q Truck <br /> Longitude - I Q Planned !OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other — —LAN�h,�ili•� <br /> Part B-Inspection of Waste Tire Dealer,Generator,.Hauler and End-Use Facility I ENFORCLLE��MENT STATUS✓7 <br /> A A LNG AND MANIFEST EQ IREM ENO S <br /> Q Q M. Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requi ed for fYO V or F>CT) <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 f rred t CIW 8 En orcement <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 Gom liance - No Viol tions <br /> 1010 1 Other. §, <br /> Comments 6o�D/���T�—�5 # _'3 /_D_R9_zZ�_. <br /> �O-kc���y�l_/izr'a_Gi�bEblPit C.O_y►_ce_nrr:_v9�s/�sT_���c_�/��t.�re��,t..,s <br /> dZI 4014 AA� 10"A <br /> ✓r d 10-A7 Md. _ <br /> O <br /> Inspection Form Included: <br /> CommeQ <br /> ;,(,c��, __ —a„r�_468 `76' 3 <br /> nts Included:Q r <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK 50rree; 1 E I X I a IM I P I L I E I I 11.2131 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />