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822704019.8 <br /> Waste Tire Survey & Inspection Repod Inspection Report Number <br /> State CfWM rCalHomla SurveyForm - Page 1 12 - 1 01 0 8 7 4 <br /> CIWMB 181 t ew nage <br /> ' CalHomla Integn[ed Waste Management Boerd. <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / O n / _ Inspection Type (Fill one) <br /> Site Su x: (� ('� U 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �/7t/�J ITO=U ari &Q _t_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By. Inspector <br /> Physical Add I a?j _ F6D41 <br /> , ��,L( 11A,1DgJ <br /> IS 345-0 AL17-0 ?t.A� bJ.4-t,�� - <br /> Street <br /> +51 RN <br /> Inspection Date <br /> City—� State 7 1 ode Time In Time Out <br /> Business Rep Title 0 AM 0 Am <br /> m'MOPM m 'm O 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 /> j I �—5 5 <br /> L— 0 Active 0 Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m, Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ F 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 Relreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body I♦Car Dealer Q Collection Q Crumb Rubber <br /> Q service Station Q Hauler Q Agriculture Q Shredder . Q Other l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 Oate m / m / m <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 Submittal of Manifest Forms and Tire Trip Logs Within 90 days ( equred Jor NOV or <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 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 C-ompliance o Violations <br /> Q Q Other: § <br /> Comments <br /> KaK-�+�+/�_�i���f_r�n� o+�L�a_._e�•_c�'�t. ike_�p�!/cya�q eJv_a_•JOf_7�-%�.5_ <br /> V�ac��_d+�u,a.c�f_��_S div✓_ii e�tnc.-�� a.a_ i�..-r. /'_ Y�..,..✓ �� �a...2-t--��S <br /> •i�—`_ I'1•L W <br /> 6' i t,4o� Carel-TfT._•.9 •�I-t^ <br /> �c,� .4�'S � <br /> Inspection Form Included:Q 1/A 01, <br /> ��/( L/ A e Oq <br /> Comments Included:Q / _D3- =�-I- — --`� <br /> �&sinessRev's Si nature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect: Incorrect: IM X A P 62081 L E 1 2 3 <br /> ■ Whit Copy:CIW Yellow Copy:Operator Pink Copy:LEA ® S <br />