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07354040058 <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> CFWM}CaiRomla Survey Form - Page 1 - I 5-- 1 0 735931 <br /> ctwMe'181(N..ovo+) <br /> Cdifomla Inberated WUN M—g—t Bond .. <br /> PartA-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- I I Inspection Type (Fill one) <br /> Site Suffix: /1y 9. �i � ' I •Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I{ I If Referral,choose referral type(Fill one) <br /> Identifier: L_ e- 4� „ J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I i <br /> - �� j� -� _3 > � <br /> Physical Addr <br /> ress ' J <br /> ` IF <br /> Inspection DateCA / <br /> �7 n,&, Time In Time Out <br /> Business Rep Title I�_ --� Q AM Q AM <br /> I A PM i PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> ,y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) t r (T/'/ <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> 'O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> - O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply). <br /> 0 New Tire Dealer 0 Auto Repair I&Trucking Fleet 0 Government 0 Retreader 0 Dismander 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 /> I ' <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS 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-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m/ m / m <br /> 0 0 14 CCR§18459.1-The Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs wilhin.90 days (Required for NOV or am <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations _ <br /> 0 10 1 Other. § <br /> Comments <br /> C9v� �s—G�ta. /� 11✓_077.�s '2/2 t[AVio/ _ <br /> jCf F el%,�%Sores L✓ —%arc_, <br /> ,'t /Q���ot c�0 crcty�r_art.i'k�r i�a_};.XL_/1a�1aa <br /> y r•y 104--r'.UVA-S <br /> Inspection Form Included:TO& <br /> Comments Included: usiness Rep's Signature Phone Number ns o s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect:KA q EX A(6p M P L E 1 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy.LFA ® ■ <br />