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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 8WMB 181(Nrnla Survey Form - Page 1 1 3-- 1 01 3 6 8 8 <br /> CIWMB 781(New 04104) <br /> Callromla Integrated Wash Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile — - Inspection.Details <br /> TPID- Inspection/ - ^ Inspection Type (Fill one) <br /> Site Suffix: 2 ( V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sQQL ✓ll�,..� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C` Q ao al- <br /> % Inspection Date 0 / S^ / Q 6 <br /> �� ?5-377 <br /> Time In Time Out <br /> Business Rep Title / 2 : © O AM n C� Q AM <br /> �T �/��CG `'`7Q�t Ll�G1'_' ----r _ -- -----•PM � L / �PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator &Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMOEM R ENT^�7ATUS <br /> . , <br /> Q Notice Of Violation G Extanslon <br /> Q I 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 -- ( T <br /> Q Q 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements y pate F / <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 (kequlradfor rvDV t r <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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> QQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § gift <br /> Comments '1-se % :1 K �Lt idr/ •/� d f�P wgy ��r <br /> 2_0 6VI'al W-WA 94-ez&j Py .4 Me- ,4 jtt`� <br /> - � �� �. /�✓ tai aC.:-r��-r. <br /> ,Inspection Form Included:Q <br /> Comments Included:O <br /> Hess Rep' ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPIL E 1 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br /> 0629804.0.348 <br />