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- X9091090296 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> n' <br /> CrWM,Calfwna(16/ 14 - 1 0 1 3 5 4 9 <br /> CfwM6 1B7(New 06) <br /> Form - Page 1 <br /> Califomia Integrated Waste Management Board Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Proflle Inspection Details <br /> TPID- O I Inspection Type (Fill one) <br /> site Sufftx: O O *Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier. (����)�F�/7A Q CHP Q CIWMB Q Complaint Q'Educational Visit Q Other <br /> Business or Faclllty Name "' <br /> Inspected By Inspector <br /> �� , <br /> Physical Address � � !✓ f 'rCL <br /> 3-5-o(D - <br /> Street <br /> � `4 Inspection Date <br /> 30 v <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> BPM D Q� O D ®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 /> _ <br /> I° F 1. 1� ®Active ®Passenger ®Generator ®Outdoor <br /> 0 O Closed Q Altered <br /> m <br /> GPS Latitude Q Hauler Q Indoor <br /> m Q Inactive Q Truck ! <br /> Longitude IO Q Planned Q OTR Q End-Use - Q Container j <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader O Dismantler Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> rJ '• <br /> O Service Station Q Hauler Q Agriculture Q Shredder O Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST RE3UIREMENTS Q Notice Oi Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / El <br /> O 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 EXT) <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/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 ® C pliance - No V'olations <br /> Q Q 1 Other: § - —e 1_ ,/ <br /> Comments ,{�' �,n i n C n r�; �S UCatRp n�-1 mil y/ i l!g r,h a a� <br /> Wiles (/1Jv stV-e— 'Rea <br /> Rn r n`vp I,I,, [[WJ <4— t" wasi-`. j re l„l.-Cn r,c✓�Q,-,—�J�t:� �,J'_�— <br /> 2 U q JAZ—�'LC.uA/V�J_'P�T [J,�1 r►►t Sy i t'W�U _ /�10 ✓`r'"`0'L�� �ha 7Qs�eGQ <br /> Inspection Form Included:Q n <br /> Comments Included:Q a 1 7 �4�n_aUure_ <br /> 4 �jBus- s Rep's Signature Phone Number InspectorPhone Number <br /> INSTRUCTIONS ON ACK Correct: Incorrect: E X A Ah P L E: 1 2 3 62081 <br /> ■ - White Copy:Cti Yellow Copy.Operator Pink Copy LEA ® ■ <br />