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== Waste Tire Survey & Inspection Report Inspection Report NumberSlat ■ <br /> CiWL (ornia Survey Form Page 1 1 1 2 8 6 7 <br /> C1WB 181 181(New 04104) <br /> cali(omia Integrated Waste Management Board � <br /> Part A- Survey BLUE OR R BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �^7 4 Inspection Type (Fill one) <br /> Site Suffix: } '3 -� 1 ! © rQ Routine ® Re-inspection <br /> Q Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: •r �H � i� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- e ✓ i Inspected By Inspector <br /> Physical Address V C) C) <br /> inspection Date Q �7, � Z C) 5 <br /> Tu•-� �[ Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 4 1 �� 1 0PM 0PM <br /> �� V I GTGI"j h CJ C.L�i�'K�yq <br /> Operational 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 /> ( •Active ®Passenger Generator Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - I 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 O Car Dealer Q Collection Q Crumb Rubber <br /> iQ Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility („ENFORCEMENT STATUS_ <br /> , _ I. HAUL NO.AND�M�4tYI MST-R QUII MENTS Q Notlaa at Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cgl11$11)4gae p0at3llne <br /> Q O (PRC§42956-RegistrationlDecal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q I O 114 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 ( (l�egtled[orNOl/arEJln <br /> Q ` Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q[�eMPltt�� fiNMB EiorgRmartt i <br /> rri � y <br /> 01 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> s <br /> 0 - 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f <br /> Q Other: § <br /> S I" t, <br /> Comments i5 (-7 2ot-� t fGr+�a.+r- �,-•, <br /> lnt� 1 <br /> 410 <br /> -his - s remit' <br /> P 4-s <br /> I Jlo <br /> -- r — — <br /> Inspection Form Included: p y <br /> Comments Included: 10 - - �c,�r— <br /> `Business Rep's 3 nature Phone Number s gna Phone Number <br /> INSTRUCTIONS ON BACK lft`t >I t` � .` F' f��t` 3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />