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Waste Tire Survey & inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB Waste <br /> eManag) Survey Form - Page 1 1 9 - 1 01 4 7 0 9 <br /> California Integrated Wasfe Management Board <br /> Part A-Survey BLUE Q� BLACK INK PEN <br /> Business ProfileUr" F._ I Inspection Details E C '- — —- <br /> TPID- - Inspection Type (FilonP)� <br /> Site Suffix: 1 i� (� t Routine ORe-inspection+f OReferral <br /> 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint O Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> t' U <br /> Physa al Add ss <br /> -c:6(2< <br /> Inspection Date L I <br /> � -� 5�' <br /> Title <br /> 1 Time In Time Out <br /> Business Rep r O AM Q AM <br /> O PM O PM <br /> Y-Wt 'Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) o <br /> 4l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> `t ® Active Passenger ® Generator Outdoor <br /> Latitude o 0 Closed 0 Altered + <br /> GPS O Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned O OTR O End-Use 0 Container <br /> i <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 ® Car Dealer 0 Collection 0 Crumb Rubber <br /> 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 STAT( <br /> V I A. HAULING AND MANIFEST REQUIREMENTS ti <br /> 0 Notice Of Vlalation � 6t}r�A <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires rtt <br /> y <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compllarias <br /> 0 0 PRC§42956-Registration/Decal in Vehicle pesltlllrte <br /> ✓/�� <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> OO 14 CCR§ 18459.1 (aj(b)(c}-Tire Program ID Number from CIWMB <br /> (i?equlti�d far NE#I�ar <br /> 0 ! 0 14 CCR§16459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ai <br /> .> <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0-ROO" #:1. <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use FacilitiesJ. <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ; <br /> O O Other: § <br /> r.OrnmentS U-* 4� <br /> R► ( &u'r/ d'� tN cJ}�.t' ��'�y +�. �jt X o Yom- � �o V•�cl c%� wut 1'5 �— <br /> ( ` t-tJ�� W� to��� i�K S tti►1h C tti i V� .q..t h <br /> UMC. 7 S �� 1� <br /> 16- <br /> Inspection Form Included: 0 L4,9) ti.0 c�0 -Tv-r� ` OqL ` 4\k-- <br /> CAI <br /> Comments Included: 0 <br /> Busines Rep's Slgnat re Phone_ Number inspector's Signature_ Phone Number <br /> F .. -. _ <br /> C <br /> INSTRUCTIONS ON BAK (Clamed In <br /> ect A rµ p � s2aa1 <br /> y ~r <br /> ■ WCIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />