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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate 5lei <br /> (NeCalifornia Survey Form - Page 1 I 9 d 4 71 7 <br /> CIWMB 181(New naQ4) Y <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR_ BLACK INK PE_N <br /> +Business Profile y - _ Inspection Details - I <br /> TPID_ - Inspection Type (Fill one) f <br /> Site Suffix: t Q 5 t 5 U 4W Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �J <br /> weo .;M(/1e!„�,. � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ (T <br /> Inspected By Inspector <br /> � hysicai Address <br /> u►�ta O <br /> 1755 <br /> Q / T <br /> 6A / 5 �� / inspection Date <br /> (� i <br /> Time In Time Out II <br /> Business Rep Title O AM O AM I <br /> 0P 0P <br /> Operational Status Tire Type Business Role II Storage Type ll <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply)I (Fill all that apply)I (Fill all that apply)I <br /> 1 ' 4f Active ? 9 Passenger 0 Generator Outdoor <br /> O Q Ciosed Q Altered <br /> Latitude GP$ O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned 1 Q OTR I O End-Use I Q Container <br /> ` Business Type (Fill all that apply) <br /> Q New Tire Dealer IS Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel I <br /> Q Used Tire Dealer Q Auto Body 4 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1-ENFORCEMENT$TAT.U4 <br /> V A HAULING AND MANIFEST REQUIREMENTS I ' <br /> Q Notica fJf Vlala�lon Q ti <br /> O O PRC§42951 �tE%-Waste Tire Hauler Registration and Transport of Tires s� <br /> O O IPRC§42953-Contracts with Registered Waste Tire Haulers. <br /> I � Complianes Dastdly+>< - � <br /> O ? O I PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements m <br /> ( •Data( ( ( J �/ <br /> Q O ' 14 CCR§16459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> /Requit sd la Nl3Ya� <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days 'Y� <br /> O O 114 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 t�fjY� l� Ia <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesI`sw <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Commentse�V . kew C-d�.r ,t C Q 1 "��.5 ��- - __1\k, <br /> ,,.ra,a v�tstc c� : , -�S wu���h,r-� . �t�1 vr-a►,s�c <br /> Nuc— . �act}� VW Npeev�,,N"\4-ryv\ej,__ <br /> Ifnspection Form included:* <br /> Comments Included: <br /> Business Rep's Signature Phone Number nape c ure Phone Number <br /> INSTRUCTIONS ON BACK 1-C"_ <br /> Ct l�.:`Ih00lTeGt:. PJLJEJ 111,zL3J <br /> 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />