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a <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of181(Nrnle Survey Form - Page 1 t 7 - 1025605 <br /> CIWMB 181 stew nage <br /> 4104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 1Business Profile Inspection Details <br /> TPiD- � - C f Inspection Type (Fill one) <br /> Site Suffix: 3 © &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> E- <br /> Identifier: `��r Jv stir � L O Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> III <br /> Business Name Inspected By Inspector <br /> Physical A' ddrets �� <br /> AAo <br /> Inspection Date a �? l 057 <br /> Time In ✓ Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type � Business Role � Storage Type i <br /> Tire Count(Whole/PTE) ) I(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r I ®Active ® Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® indoor <br /> O Q Inactive I Q Truck <br /> Longitude - O Planned 1 Q OTR I Q End-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> 40 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Reireader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q 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 FacilityENFORCEMENT STATUS <br /> HAULING ANp: ANIFl$T Ri?QUIRMENT8 <br /> O Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O !14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Q ' <br /> • Q 14 CCR§18459.1 (a)(b)(c) Tire Program ID Number from CIWMB 11taIE / m / m <br /> O + O 14 CCR§18459.2.1-Submittal of Manifest Farms and Tire Trip Logs within 90 days I (Regt4WforNOVorE)M <br /> t <br /> O 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 I R4htfeq 7 ctYllllOB Sftforcoment <br /> Q O .14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 0 Other: § VI01trt)Ofla-- <br /> Comments nkGl) " ,t!/'{'y.,' / V CJ 'Tf r04 �r 1 '�--- 51 r L, <br /> f Inapection Form Included: Q <br /> Comments Included: Q - 20 I` ^? Ob I <br /> i Business Rep's Ig ture Phone Number s tor's Sig a Phone Number <br /> • <br /> 62081 <br /> ALF <br /> INSTRUCTIONS ON BACK �'dbi ifir} �II1G4tl Ff d <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA KB <br />