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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form - Page 1 14 - 1 0 2 5 7 3 4 <br /> CIWMB 161(New 04104) <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details j <br /> TPID- Inspection� � � � � � Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit (!) Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> zf <br /> !PhysicalGfLddress <br /> i <br /> Inspection Date 05 <br /> �u7i� t 7-;7 33 6 / <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM Q PM <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) 6 <br /> Active Q Passenger ! Generator j Outdoor <br /> i <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler j Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR O 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E. FORCEMENT STATUS <br /> A. <br /> . It M ►rll� x ( Iu� �tiersl , <br /> Q Q PRC§42951 -Waste Tire Harder Registration and Transport of Tires Ntskhs9 Of YIclfAtilan. Q Extension <br /> i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. olt7plEat7 ;<tiMliid110� <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Rate / m / M <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 (RNOVorEX7) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years T —� <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ,¢ 3 �tF10fCeRlitltE <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ' � t <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> - <br /> Q Q Other: § <br /> Comments 5 4G/yGcC-. /�/L✓/ r"��j �: <br /> n. <br /> dnspection Form Included: Q 95j 7-Y 919 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspe n Phone Number <br /> s _ r � J� .;> —i..-- —� 62081 <br /> INSTRUCTIONS ON BACK � � 1i �;�t� P I �. } ? <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />