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0705M 50802 <br /> 0Waste Tire Survey &.Inspection Report Inspection Report urn er ■ <br /> Sto Survey Form Page 1 1 9 1 01 3 1 2 4 <br /> Cgmte 181(New 04104) <br /> Callromla Integrated Waab Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Inspection Type (Fill one) <br /> SiteSuffix: LJLZ} E717 / �6 '1Z ( ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `— ! If Referral,choose referral type(Fill one) <br /> Identifier- b 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V r <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date � �C7JK-71 <br /> t <br /> City / State T_1P Coda Time In Time Out <br /> Business Rep Title O AM O AM <br /> MOPM m O PM <br /> - /hC_X,P���J L — J Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholotPTE) 1 /L5-I O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 8 Active ®Passenger 0 Generator 0 Outdoor <br /> -- - 0 0 Closed 0 Altered <br /> GPS Latitude I 0 Hauler 0 Indoor <br /> - - 0 Inactive Truck <br /> Longitude _ 0 End-Use 0 Container <br /> g I 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantier 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility EN_F_ORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS I 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-RegistratlonlDecal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 • 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other. § <br /> Comments —5,-b <br /> Inspection Fonn Included:01 " <br /> Comments Included:+ - { 7-3866 <br /> I mess Reps Signature Phone Number I_ or's Signature Phone Number <br /> INSTRUCTIONS ON BACK (Correct:* incorrect:" ("i4 j,EjX AIMIPILIEi 11!2131 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operalor Pink Copy.LEA �� . <br />