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Waste Tire Survey & Inspection Report Inspection Report Number <br /> im <br /> State BCalifornia Survey Form Page 1 f 4 1 01 4 7 2 0 <br /> clwMB tst Waste <br /> l y <br /> Callfornla Integrated Wasle Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ D Inspection Type (Fill one) l+ <br /> Site suffix: t O O 0 Routine 0 Re-inspection 0 Referral 0 Observation ' <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sq �r^ �� O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or FaciNty Name Inspected By Inspector <br /> Physical Address <br /> 1C.d k 4125VO�-oIAND_-> <br /> v l o rkv\ S�. <br /> 5���� � -5�4 /� Inspection Date ? z / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational StatusTire 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 /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed , 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler ® Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber —T J <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other y <br /> y CJ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMFNT:STATU4 .. <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notic#Of Vlalatlort.. +� ttxt rt�fi>wn <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 ,PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Dekilinp <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 .14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I I <br /> f4 CCR§ 18469.1(a)(b)(c)- Tire Program 10 Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RAqulredforNQV Ot <br /> O O I <br /> 0 0 <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 1 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 ClliliMB >n ft J)�/ ' <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Ih C.mpli#l�Q4 t� �V � .,,i <br /> 0 0 Other: § — .. // ' s. .�✓�� <br /> Comments 1'"'7 j e���, v jS Garrc�f' 2✓1 vr.(a %�l�jOn aca�� <br /> � /I� � d fir <br /> 7/ Y� 6 �i /s 794 <br /> prckd o ct9 /�z o� WAZ .44�� a--��'t 4GT/tr. „ �NT S�?o�tla( Ape- �t cwr'.0 QS <br /> / '�i4 J�"� rr QCGo 7a `-r WAO 444n� • It ;r11 ew Or 6l <br /> Inspection Form Included: 0 I f �L74 <br /> Commants Inc)uded: <br /> Business Rep's Signature Phone Number natu pho Number <br /> INSTRUCTIONS ON BACK I Correct: incorrect: (�} l M P L E 12 3 s2oa1 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:Lf;q 5A <br />