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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CfWMl fill <br /> purvey Form - Page 1 - 1 Q U 3 2 2 <br /> CNVMB 181(Now 04104) <br /> Calilomia Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection i3etafis i <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 3 6 -7 $Z O Routine ® Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��7�e� 7 ELI i �Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> .Physical Address ! <br /> i <br /> Inspection Date 6 / O J s <br /> ��q 9533 0 ` <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> O PM Q PM <br /> `Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WltglelPTE) <br /> ! (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> � r � � <br /> 0 Active I Q Passenger *Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude I � Q Hauler Q Indoor <br /> O <br /> 0 inactive I •Truck ! <br /> Longitude — 10 Planned I Q OTR , O 1=nd-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Reireader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> C)Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Bart B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFQRCEM.-NT_STATUS <br /> V ( A I HAULING�ND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 ' Q PRC§42953-Contracts with Registered Waste Tire Haulers. ( Compliance I eadline <br /> O , O PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Date ED <br /> / m m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 9D days <br /> (Requ red for NOV or W <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ` Q Raferred J I!1IWM8 Enforcement <br /> I <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 4 In Comolk nao - No violations <br /> 0 , 0 Other; <br /> Comments ��/I TT- (j t'/1o"'�" I'�cthl l,h� V✓''`,ri'f�-/vj5�� ^-'-�I�I„e-�^g`� —�^�Jt�' <br /> cam. gyros -&r,-.i L-ks Sa4, CA R G 1 4►s l <br /> Inspection Form Included: 0 <br /> 1 / 1�f ►/ �G� ���� ?�G i ��I�� <br /> Comments Included:Q ////iv/h 1�4/'/ J <br /> Business Rep's Slgnatur Phone Number Ins ckanturaPhone Number <br /> INSTR C 10 ON BACK 'Corf,act:a! Incorrect: <br /> 1v1 1C �+ N�IF�'LJ� ` 62os1 <br /> n�er�� - — <br /> KB <br /> White Copy:CIWMB Yallow Copy:Operator Pink Copy:LEA <br />