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073120SO028 <br /> �= Waste Tire Survey& Inspection Report Inspection Report Number <br /> s""G1Ff'_1a Survey Form-- Page 1 1 2 - 10 7 3 3 191 <br /> CIWMB 181(Naw taloa) <br /> calitomia Integrated W.M.Management Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspection Type (Fill one) <br /> Site suffix: to Routine Q Re-inspection Q Refenal 0 Observation <br /> Local / H Referral,choose referral type(Fill one) <br /> Identifier: Jam �Q O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street C c�'1�_ h <br /> f G�g�ID I Inspection Date O 9 <br /> City [ tate ZIP Code Time In Time Out <br /> Business Rep A TitleF O AMM O AM <br /> 0 PM -[_Lj 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> l <br /> Tire Count(Whole/PTE), (Fill one only) (Fill all that apply) (Fill all that appty) (Fill all that apply) <br /> � <br /> r ' ✓ Q !Q ®Active ® Passenger 0 Generator ®Outdoor <br /> GPS Latitude I Closed Q Altered <br /> 0 Hauler <br /> IndoorL1IL _ L �OQQ Inactive ®Truck <br /> Longitude I Q <br /> Planned ®OTR S End-Use ®Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet O Govemment ®Relreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Hauler O Agriculture O Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility E_NFO_RC_EME_N_T STATUS_ <br /> V A i,HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q 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. i Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 Q 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 <br /> System Requirements for Tire Dealers or Wastes Tire <br /> ree.Generators ®In Compliance - No Violations <br /> O Q Other. § E a• G(/T$ V I B1,(J� t1'OWf (�,�o(ah ^Y' t S <br /> Comments rvvr <br /> 81 ike 1±15 iptr`f d5 _. iS—_ _cam�.[�—p� i'2_capl� <br /> leek evct "✓it 2 f�C,kStawt S. �-am l s of tent or wtor _fir�S <br /> _fie _car►e--_WU('Ct' r-j 'St'W--e_ce V V C)eZ6 ets"_TPi Dom- <br /> _ `✓>`t .la ft,9�l , _ o.�_ hA S_ t/Ic� �i- �S ��n_o+ <br /> Inspection Form Included: <br /> Comments Included:Qjimess— —Signature Phone Number s ct S nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect:X(J� I AMPLEI 111213 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />