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08066U4U050 <br /> Waste Tire Survey & Inspection Report p port Number ■ ' <br /> .,..• ins Inspection. <br /> �to suteeroaiteM Survey Form Pagel 15 - 10 1 0 8-4 4 <br /> 181(Haw 04!041. <br /> Califomla IntCIWMBegrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / - O Inspection Type(Fill one) <br /> uffix: <br /> site Sb 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: � w/OQ men�'1 _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 6 Inspected By Inspectors <br /> Physical Address <br /> "?9-7 i <br /> Street <br /> Inspection Date <br /> I <br /> ity State Zip Code Time In Time Out <br /> Business Rep Title O AM 0AM <br /> :F70PM [El: 0 PM <br /> cl Co 7 ! CJ T`�¢r7ee^r et0�� <br /> ( ) t� Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE � I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> is Active (§Passenger *Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude m• 0 Hauler ®Indoor <br /> 0 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 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility FORCEMENT STATUS <br /> V A ;HAULING ANO MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date s / s <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> / <br /> 0 0 14 CCR§18459.2.1•Submittal of Manifest Forms and Tire Trip Logs within 90 days (Re red for NOV or EXT} <br /> 0 - <br /> 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 Referred/C-IWMB Enforcement <br /> 0 1 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 1 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 1 0 Other: § <br /> Comments <br /> �-� V <br /> inspection Form Included:0 <br /> Comments Included:0- - <br /> Bus?essep's Signature Phone Number Inspector's Signature. Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 1,112131 62081 <br /> . White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® S <br />