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_ os>tg2o�oo2� _ <br /> rtit0_ <br /> Waste Tire Survey.& Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB1811st(No w01lge Survey Form - Page 1 1 3 - 1 0 7 9 3 3 3 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l 2 f [� 2 Q Inspection Type (Fill one) <br /> Site Suffix: I .� I I 1 1 3 y 1 O 1 Lo GR ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identifier: ___ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> —J— <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Ad j s - ( Q <br /> �_ �.� L�l_�y_t,rtit, <br /> 1 a q(y s r <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title I ®AM Q AM <br /> n I D Q PM / 3 U ®PM <br /> - Operational Status Tire Type Business Role' Storage Type <br /> Tire Count(Whole/PTE) 13 /� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f l ®Active Q Passenger ®Generator Q Outdoor <br /> PS Latitude 0 Q Closed Q Altered <br /> G <br /> (0 Hauler ®Indoor <br /> Q Inactive ®Truck <br /> Longitude - i 1 I Planned OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 10 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer- . Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility RENEORVEMENT STA US <br /> V HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of 'Iola io Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ate Ell / m11:1 <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required forNOVor <br /> O 10 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I C-IWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 10 .14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In C-ompliance - No Violations <br /> Q 1 O 1Other: §, <br /> Comments kotdv I�5�yec9n <br /> J�s �D r -Us Ai rfna& b-as es . Tires -ems a.r-e Sorgqn-v­ <br /> 51po5ai adu e T;ro—5 on S i+-,e, Cc,c aY•2 Wield )a C <br /> (tpv� a-s <br /> Inspection Form Included: Q <br /> Comments Included: VreS <br /> usin ss Rep's Si nature one Number Inspectors Sig Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK Cor ect� ncorrect: JE.jXj.AjMjP[LjEj 1112 3 <br /> . White Copy. IW Yellow Copy.Operator Pink Copy.LEA <br />