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iL ; Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stateof181(Now <br /> NSurvey Form - Page 1 l 4 41 4 869 <br /> CIWMB t81(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> (Business Profile- Inspection Details <br /> TPID- O / _ Inspection Type (Fill one) <br /> Site Suffix: SCJ If Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: � -Foci-{Y\ c0yt,I,r�(,t- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �/;,rf�' <br /> VA Inspected By Inspector <br /> VIS a v-rl _ <br /> Physical Address �� 0 ( Spu,� �t(� <br /> o0 Awh p62-k VVxy <br /> Inspection pate � � � q <br /> qsS c I <br /> Time In Time Out <br /> Business Rep 11 Title Q AM Q AM <br /> ' <br /> N a-1 e S 1 lev 2ocr S 7 q_7�3D QPM QPM <br /> Operatlonal Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' U 0 Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed 0 Altered l <br /> GPS Latitude 0 Hauler I 0 Indoor <br /> O 0 Inactive 0 Truck , <br /> Longitude - 0 End-Use 0 Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body IR Car Dealer 0 Collection 0 Crumb Rubber <br /> I,0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT 8TATU$. i <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauter Registration and Transport of Tires 0 Notice Of.Violation Exten#ton <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compli.Ance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dani <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR 16459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days fRiWihiid(orNOV4ti„ <br /> 0 , 0 § P 9s <br /> 0 i 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Retefrgd/G1WII)l IafOra�j[,I�IfI {� <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 i 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators xs <br /> O,Irt CgmplW>>tse MI. <br /> 0 0 other: § _ _ l —"' _ ' "1 i�/ <br /> CommentsA ffcox)�Q[ IV (tt^) <br /> vict s '2 -T vts 0 Y1 _Sf� � 5 v✓iQa1 2 r i z-f-l7 <br /> oL�•aita.��1e � ���iFes� cul cz�'c�.lat.bl� . �aCili� ttises. re iS��t''eG� 1����� �+' <br /> t-p d VV;1 I re Ieyl iii d4" s .it v i e cv l4ja�� Tre A1a1; s7L5. <br /> Inspection Form Included: 0 `,� <br /> Comments included: 0f2- ��- <br /> BAus Rep's Signature Phone Number In toys i nature Phone Number <br /> L?� <br /> INSTRUCTIONS ON BACK [CorrW.4; Incorroct:XrN E X Ah R P L E I 3 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br />