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0822704'0107 <br /> ■ � - Waste Tire Survey &inspection. Report. Inspection Report Number. ■ <br /> r; 8""calgomta - Survey Form'- Page 1 - 1 5 - 10 7. 3 4 4 5 <br /> !WMe 181(New(W04)' �. <br /> califomla tntegmtod Waste Management board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: .� 2: I - •Routine . Q Re—inspection QReferral <br /> Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identlfler. �rQ f/ d,q� ,-^/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name. Inspected By Inspector <br /> I <br /> GaZA�7Z-A-i�le2_s <br /> Physical Address 7 <br /> l 0-T=� �62.L-OG—ICd� <br /> Street <br /> q5Zl'7 1 InspInspection-DateInspection-DateioDate �h <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title OA <br /> M11yGiL Gf7GSTEoTT �LCtNT/e//�/ m <br /> Mo <br /> PM 0 AM m m 0 PM <br /> -_ — Operational Status Tire Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 - _ I�� <br /> L_ 1 Actve Q Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude mQ Hauler Q Indoor <br /> O Q Inactive 0 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 /> i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of.Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMENT SITATU_S _ <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 /> 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 EX7) <br /> Q Q 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 f -1 MB 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 1 Other: § <br /> Comments f�N <br /> otr„r:JG inlSd <br /> A,Af�• A,4,6n <br /> a <br /> Inspection Form Included:.Q � <br /> - <br /> Comments Included:Q <br /> usmess Rep's Signature Phone Number Inspector s Signature Phone Number . <br /> INSTRUCTIONS ON BACK' Cor ect. Incorrect: E X R M PILIEF1112131 62081 <br /> ■ White Copi cIWM Yellow.copy Operator .Pink Copy.LEA ® ■ <br />