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r <br /> 08325010076 <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> CFWN18 °`nla <br /> 11 1088033 <br /> CfWMe, atleManag) Survey Form - Page 1 � _ � <br /> Calilomla fntegrateA Waste Management 9oard <br /> Part A-Su= BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- u i I 1 - Inspection Type (Fill one) <br /> Site Suffix: 1 Q I f 4 2� I Q Routine Q Re-inspection Q ReferralIs Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier. SQt1 TOQqU1fl G Ot.1n rJu� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address 3 9 LKr i_sti_an—LacaS__1 <br /> � ?_*�-L._W_t lsh 1 t'e—_- ve. <br /> Sirosr O R <br /> Inspection Date71 � 1 �-+ <br /> O --- - —--- -- <br /> - - -- - A - Boa <br /> Sit c n _C 95,.Cc 6a <br /> Time In Time Out <br /> Business Rep Title - -- O AM - -— O AM <br /> Q PM O PM <br /> -- - - - <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ' ' 12� Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Inactive Q Truck /w <br /> Longitude O Q Planned Q OTR Q End-User A Q Contain(n <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 0 Other L�5if1ay� �eGo(ds_-S�o_rayg <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 •In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments ' <br /> yo�_��Q�_-s�n�cQs�orr�tt:�. Ttt�a�er�t►ons,�ve�„�_ece—G�'�tve @. -this <br /> &IAiil-.,A11_Uet��c_I ,s have rnQ►nterk_gnCP_p.e_6med 6 -st't.r_L s s hwab <br /> Tire. Cerr�e.�sgerci��e E. bra mac, T. ReGordS Mn[is�� deft+. <br /> Res-omm_R�r1�_f�ir�c c _���► e -r P 1 D 1551-4-02--02-01 . <br /> Inspection Form Included:Q (?-o9 <br /> Comments Included:Q— §7_` oq6S—�jpp's <br /> r gnature Phone NumbergPhe Number <br /> ( 62081 <br /> INSTRUCTIONS ON BACK Coect: Incorrect: <br /> ■ White opy CIW Yellow Copy.Operator Pink Copy LFA ® ■ <br />