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08129040fl60 <br /> € a Waste Tire Survey & Inspection Report Inspection Report NumberState of ■ <br /> ra C"S1eleomla Survey Form - Page 1 1 3 - 1 0 7 2 8 0 9 <br /> Cgrate tet thew n"e <br /> CalAomla Integrated Watt*Nanagemant Board _ <br /> j Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- f— ' I u Inspection Type (Fill one) <br /> Site Suffix: O Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �� �Gyq Q,4t/� COavov 7101-- O CHP O CIWMB O Complaint Q Educational Visit.Q Other <br /> Business or Facility Name (J VInspected By Inspector <br /> dirt el i 1�1 scat {t s 3 <br /> Physical Address <br /> �32c 5 AD Ap- �Zi7. <br /> RA- <br /> Street Vq <br /> �]p J 2l 5 Inspection Date <br /> City� G� tate ZIP Coe Time In Time Out <br /> Business Rep Title OAM O AM <br /> —�`I <br /> e f. 1--(Wks,--.—'`tJt"n-�-' --L --u EE 0 PM M 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f I !� (Fill one only) (Fill all that apply) (Fill all that apply) (Fitt all that apply) <br /> r ° 0 Active O Passenger ®Generator 0 Outdoor <br /> j I <br /> I I O O Closed O Altered <br /> ��GPS Latitude I i I. __I _�IO O Inactive O Truck O Hauler O Indoor <br /> Longitude _ I I I I I -�1 O Planned OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> i <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder 40 Other ,�om2��, OoI1ajL� <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m/ m j m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 O Referred/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 1 Other. § <br /> Comments L r- C L/L 4-�e—S <br /> —?-Ae1'��s—�—`�te.r'�(aa,9�e��2e`�j-a�cl_e _�V_lA�l' is <br /> VleLJC4 Va Vffl(&�t"-S— 401L G—PPI CC ©Pecb- <br /> inspection Form Included:O <br /> �i "M��30 Comm, Included:Or - <br /> Bueiness R 's Slgnatu Phone Number In pectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( j;F]F—ETTAFmTPNjE1 111213 62061 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LFA ® ■ <br />