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08129040741 <br /> Waste Tire Survey& Inspection Report - inspection Report Number <br /> 5tataofa1(emia <br /> Survey Form - Page 1 1 2 - 1 0 7 9 1 9 1 <br /> CIWMB/B1(New ON04) <br /> Cellfomia Integrated Waste Management 9oaM — <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> �7 /� Q 2 Inspection Type (Fill one) <br /> TPID- <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local //� If Referral,choose referral type(Fill one) <br /> Identifier: N JOA9�. i� `Q0 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /f _ <br /> Inspected By Inspector <br /> 6A(VO_ fir;2e ! A _ r <br /> Physical Address 3 1, r 6 <br /> L_�gz3�- �. NA;i y z 6 <br /> Street 0 Z <br /> / INQ CA <br /> City State ZIP Code 752 Inspection Date <br /> L_t.._,— J—� Time In Time Out <br /> Business Rep TitleM '=Q AM Q AM <br /> • �' <br /> salva,_Jor At,ws- „ Ow^JeQPM QPM <br /> � - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fin all that apply) (Fill all that apply) (Fill all that apply) <br /> t t Active 10 Passenger a Generator 40 Outdoor <br /> Latitude I i i D Q Closed Q Altered <br /> GPS j — I Q Hauler Q indoor <br /> --_0 0 Inactive Q Truck <br /> Longitude — I f I I I i Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> I*New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel ' <br /> I <br /> 1011 <br /> Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection' Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility NENFORC-EMENT STATUS <br /> V A HAULING AND MANIFE-ST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> O Q <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. 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 IO 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 <br /> 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 System Requirements for Tire Dealers or Waste Tire Generators In Co pliance - No Violations <br /> O O Other: § <br /> Comments fNG%N.S�C.t#r�._a7t— S .44-ill <br /> /,dere- Vi e�Je._ A_1D Ut b Co N_c Brits/l.lo f_e <br /> Inspection FormIncluded:Q � � <br /> Comments Included:Q— // QUOi � <br /> sine s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: N►X a P [L E 1 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator • Pink Copy.LEA <br />