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09091040430 <br /> waste.Tire Survey & Inspection Report Inspection Report Number <br /> gtete of Cali,umla Survey - Page 1 .1 7 1 01 3 5 8 41 <br /> CIWMB 181 INew 04!04) <br /> Califomfa Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPIDI U-1 O / O ' Inspection Type (Fill one) <br /> Site Sutffx: ®Routine Q.Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Is <br /> an- OCL ►� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other. <br /> Business or Facility Name- — <br /> F <br /> -(, Inspected By Inspector <br /> Physical'Address 3 — FMot je^rl,� Fr-a s_p_ I <br /> I - - <br /> Street Inspection Date <br /> �oJ Time In Time Out <br /> it� State ZIP ode <br /> Business Rep Title ImJ Fp <br /> ®AMI f r�. ®AM <br /> O PM U Q PM <br /> _— /_� Operational Status Tire Type. Business Role Storage Type <br /> I. �( r (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE)I I l i 1 l JI 1 —�li� <br /> C, x_111___I ®Active Q Passenger ®Generator ®Outdoor <br /> OQ Closed Q Altered <br /> GPS Latitude m Q Hauler ®Indoor <br /> O Q Inactive ®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 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> OM HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q O 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 Date m / m / m <br /> Q Q 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 (Required for NOV or EN-) <br /> Q Q 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 Q Referred f C-IW 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 Q 1 Other: § <br /> h o <br /> ` ' '�I.l°S d aiie_ tAte 0—ZA 7� <br /> Comments OK- os ��yy <br /> g _ wws 7DS ta-Lae VtfilSyn KIaK Tres for Fleet gre- *_✓vl Ce <br /> a.bt:r_ f� oC�`s osa.Qs. G7Z ciK of 7- ,tif a�.�Fcst �n►^,yt s <br /> Yo ViolaAohs not o — <br /> Inspection Form Included:Q Iq q ��/ <br /> Comments Included:O / � `O�� 'I(L�B-9,960(a <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON.BACK . Correct: Incorrect: E X M P L E 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />