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08b10044186 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> tr <br /> Stateof 1(No a. Survey Form Page 1 1 2 - 1 0 7 3 5 4 1 <br /> StateCa foml 04/04) Y g <br /> Callfomle Integrated Waste Management Boats `�J' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- ' G 1i] - Inspection Type (Fill one) <br /> I <br /> Site Suffix: b I 0 t ®Routine Q Re-inspection Q Referral Q Observation <br /> Loral If Referral,choose referral type(Fill one) <br /> Identifier: Q If <br /> Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J - — <br /> Inspected By Inspector <br /> I I l6 t,h e� <br /> Physical Address [;R - Mo <br /> Street <br /> Inspection Date <br /> I 5SZO I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title �AM Q AM <br /> IE: mM:[=®PM ®PM <br /> Operational.Status Tire.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 /> ®Active Q Passenger I®Generator Q Outdoor <br /> I—� l 0 Q Closed Q Altered <br /> GPS Latitude W. T� Q Hauler .I Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Q Hauler Q Agriculture Q Shredder ®Other I Q <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility RENROMEMENTSTATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation <br /> Q Q Q Extension <br /> PRC'§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14.CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 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 FACT) <br /> Q O ------ <br /> 14 CCR§18459.3-Retention of Comprehensive 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 /> Q 1 Q Other: §, <br /> Comments S72C 110"-_&, <br /> _�d/.r_�� 'fin. CTLs—� ,`n•y�,r.Lf 1+�:..,/ ��-"��rt. Nv_�,.K s <br /> 5 �c.a�c�rt s,k . ��✓st�Z vz-is . <br /> Inspection Form,Included:Q <br /> Comments Included:Q- �6cr:lt �6Z3 <br /> mess Re Signatu Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C-orrec�Incorrect: E X R M P L E; 1111,213 <br /> . White Copy:CIWMB Yellow Copy Cperator Pink Copy.LEA ® ■ <br />