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AWaste Tire Survey & Inspection Report . Inspection 114JAV� .W3 <br /> Ste"er`'"lN Survey Form Page 1 1 3 1 0 1 3 1 0 2 <br /> cavMa rel stew Dual <br /> Cdltomla InleOmtetl Waste Manag.ment BoeN <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - f IT� L+1 <br /> Inspection Type (Elle one) <br /> Site Suffix: L I 'z � �^ ( � 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local —T� If Referral,choose referral type(Fill one) <br /> Identifier: k0­ ���,��� /� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or facility Name <br /> �'� Inspected By Inspector pp <br /> ahyai� — l�-�� _� ��� c7 LL7�+� 5' <br /> Sneef <br /> o-y C� 377 Inspection Date <br /> —Mate ZIPCode Time In Time Out <br /> City <br /> Business Rep Title 'm O PM J 10'. <br /> Hr'f te'�LtK:�, Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply) <br /> S� ®Active *Passenger *Generator ®Outdoor <br /> 10 <br /> GPS Latitude ) ) i Q Closed Q Altered O Hauler Q Indoor <br /> Inactive Truck <br /> - T <br /> Longitude <br /> Lli i _I 1 i f —I O Q Q Planned Q OTR Q End-Use ®Container <br /> i Business Type (Fill ail that apply) 1 <br /> Q New Tire Dealer Q Auto Repair ®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 •Hauler Q Agriculture Q Shredder Q Other i _. I <br /> Part B-inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ­ <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§1 B459 -Responsible Entities Complying with Manifesting Requirements Date m m /m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 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 Compliance - No Violations <br /> Comments/ �j _�'T7gGt S Z3�I <br /> l✓�.y-fz% F- LAY —� O—h-� G.72—4 f3��rn Y_f_1� /1�YX►P•+�IEw P� t-_ <br /> _(�X —� �� Ab—_ Q�,G4S{�,a 1 -I'-•iY-G C01^nyv�ir�LQ.,d( GJi-ty�. '�?s��j�.._ <br /> Inspection Form Included:Q _ <br /> Comments Included:® '^ L2' Lam' H <br /> Business Rep's Signature Phone Number ors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:X 0 9 E AMPLE 1 2 62081 <br /> ■ W h to Copy.COMB Yellow Copy.Operator Pink Copy LEA © ■ <br />