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Waste Tire Survey & Inspection Report Inspection Report NumberEtta . <br /> StWeIBat 1 alifornia Survey Form - Page 1 8 - 0 6 3 2 <br /> ClWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: k 3 b 19 - v / ® 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 /> ' v+fr— <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> h� 0 P 0 P <br /> Gl_4 Ty-1 M' Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WhoTe/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Who eIPTE) � <br /> ' 10 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler • Indoor <br /> O Q Inactive t* Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®Container <br /> Business Type (Fill alllthat apply) I <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEM NT STATU$__ <br /> 1 4_t I HAUWNG INUMANIFI3T REQUIREMENTS <br /> Q O 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ®-NotIgA.O} OIO#fOrl Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Gtant#tlhlntl:014dilne <br /> Q Q !PRC§42956-Registration/Decal in Vehicle <br /> Q 014 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements At9:FO] /Q Q 14 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 ( d fofNOVOri°Xn <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulersy` @t1brC�lilaJlt <br /> O O x}53�1k@ •£ =r S <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ._- <br /> Q Q Other: § xy'•.Ss »`y fi <br /> Comments fnVUrC•e-5 C>r Vti w\(As—(iS 0Yv5)rI�G WI-\f� f-- <br /> Inspection Form :ncunclu ed: Q _ � q( <br /> - - 73 U <br /> Comments ed:Q -- - <br /> Business Rep's Signature Phone Number Ins ctor's Signat re ! Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ti`rllll��r �4 A: I Z. <br /> Enterer- White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> KB <br />