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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> "•• <br /> State of 181California Survey Form - Page 1 1 5 - 01 4 8 9 2 <br /> CIWMB 187New g <br /> California Integrated Waste Management 8oertl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile j Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> l'� ',40 Routine Q Re-inspection Q Referral Q Observation <br /> - Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB <br /> Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P1cgIFVArVA�k <br /> t-�- <br /> Zt �O W - owatr✓�'� �O �eI\ <br /> 3 Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> \ Q PM O PM <br /> �0-t.1�Q W� CWVAV - - - <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 /> r ' Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 ® Other <br /> Part B - Inspection of Waste Tirb Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTOTATUS - <br /> --- — <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Nonceof Violation <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance`-Dgadtine <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 1 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Ra4Gired IDINOIF�I�I)7 <br /> Q I 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 HefArract7 CtM j� <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 <br /> Q Q Other: § <br /> Comments <br /> wAu� �� � <br /> �o-c5 wb� � 5 �ti or J ��t <br /> k/LS.t j�y Ips Q 6 <br /> W� _v�5 ot-<l'+1_ q/�.R u ct t�( � i TV-t- I! t v(-wrc - l a '4-c t" 0. 1'S L.L.J <br /> 4 <br /> Inspection Form Included: Q' <br /> 5 - <br /> Comments Included: Q - - - -- - - - - <br /> Sign ure Phone Numbers I Insp ctor's Sig Phone Number <br /> ■ INSTRUCTIONS O BACK Correct:- Incorrect.X (ry l FE—XIAMIPILIEI 111213 62081 <br /> White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA <br />