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Waste Tire Surey & Inspection Report�nspectio`�Repor�hQmbe� ■ <br /> St. of California SurVe Form - Page 1 L 1 3 - 1 0 7 9 4 5 7 <br /> CIW Ma,E astleManag,. y <br /> Callromie Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I Inspection Type (Fill one) <br /> Site Suffix: O 2 ®Routine .O Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S� --5p4CO-14, '% Q CHP Q CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address IT51 - ITI�141 <br /> ^ <br /> L►��wtcw_,alq_Cjc�r_d� <br /> Sfreet Inspection Date <br /> rw a 3 Ier <br /> I <br /> city r StZIP Code <br /> Stale Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> :F1 1m:m ®PM <br /> t� - NIA --�t_--------- --- <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill'all.that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE); I <br /> ' <br /> O Active 0 Passe <br /> n <br /> ger Q Generator Q <br /> Outdoor <br /> ®Closed Q Altered OHauler QIndoorGPS Latitude I JL—1 I O Q Inactive 0 Truck <br /> Longitude F OPlanned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply)' <br /> / <br /> ®New Tire Dealer O Auto Repair 0 Trucking Fleet Q Govemment- Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ®Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS Q 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. Compliance Deadline <br /> PRC-§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /m / m <br /> Q 0 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 (Required for NOV or E)M <br /> O O <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance No Violations <br /> 1010 1 Other. <br /> Comments <br /> Inspection Form Included:I <br /> Comments Included: y��' 62 3 <br /> _ Business Rep's Signature Phone Number nspector's Signature Phone Number- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X V=9( jEjjXjAMjP1L1E1 1112131 62081 <br /> . While Copy.CIWMB - Yellow Copy.Operator Pink Copy.LFA <br />