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WasteTire Survey & Inspection Report Inspection Report NumberjM <br /> CramB�p�� Survey Form - Page 1 i 3 1 Q 1 3 Q 6 Q <br /> Cgraw W sm 0418!) <br /> Galifomia lnUgrried Waste GawpemsM Bwra BLUE O$$�K INK PEN <br /> Part A-Survey _ - <br /> Business Profile Inspection Details 3470-504 — <br /> TPID• } `` G� Q O � Inspection Type (Fill one) <br /> Site Suffix: I L 1 1 O '®Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ //n�1'���.�,, it Referral,choose referral type(Fill one) <br /> Identifier: &kjb�en l R�'t•'1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ' t �//-/— Inspected By Inspector <br /> L►gAkx Used Sit Dts�►-f'c 3 _ i �uAu�� <br /> Physical Address lo 1 ► <br /> I t 8 3�► �• Nl�u.� Sfi I - <br /> Street Inspection Date <br /> State ZIP Code Time In Time Out <br /> city <br /> Business <br /> Rep Title :m O PM :F I ] O PP <br /> fiD J Operational Status Tire Type Business Role Storage Type <br /> t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> i O 0 Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> __: - _ ,.,__•� Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet ®Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O 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 I,t3VS�j ek4de__.A1P,4, I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle m <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /FTI / <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> FX <br /> (Required for NOV or T) <br /> O O — <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> o Other: { <br /> Comments ,-k lflA.S � To 11 Nqs &O/ ed <br /> �_+ ( �� tt� <br /> T�l <br /> C� e� .V r v <br /> 12-neo elf/ <br /> fir+ - f Twat !fit FDS {aci ` by /Gtc C� �i►'e / C�YS <br /> �QC�w`f1 _ {o��jTfrowi L .. Cc Cc .n I?( f eo� , S e <br /> q <br /> Inspection Form Included:QI\ �N ! <br /> Comments Included:® -1 L Ins Tors SI lure Phone Number <br /> Business Rep's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:X I� �j E X - M P L E 1 2 3 <br /> . While Copy.CIWMB Yellow Copy:Operator Pink Copy LEA ■ <br />