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td; <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State C1WM f181 tNrnia Survey Form - Page 15 - d 2 7 2 7 <br /> GIWMB 181(New 04104) <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- pp / Inspection Type (Fill one) <br /> Site Suffix: l Z O G t O l 0 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 /> Business or Facility Name <br /> Inspected By Inspector <br /> �-y ------� <br /> Physical Address / l t7 r � � �e6%zac� <br /> Inspection Date 0 -3 / 0 q / J <br /> C <br /> 3 <br /> 2 ' / <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 <br /> Tire Count (Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> I ' ell •Active Q Passenger 0 Generator (f Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 c6 — <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT_STATUS <br /> V- A ; 1 HAULING AND MANIFEST REQUIREMENT-$ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance. Doadllne <br /> Q Q PRC§42956-Registration/Decal in Vehicle rn r <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> Q Q ! 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I I t <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 Haulers Q R�fgt�rgd 1 CIWMB. Onforcerrient <br /> i <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities I <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators - <br /> jh t tpilanae No..Vlolatian• l <br /> Q Q !Other: <br /> Comments, // 7Y4�-? <br /> �Cj� /y ��/+TrGI�✓15 �''1,✓DIcS,S C,•G� !ijgl2pl[�r!� d`J �/'2S <br /> I _ <br /> Inspection Form Included: Q \\,, <br /> Comments Included: Q A <br /> 6u ne Rep's Signature Phone Numbeer,� In s Sign i, Phone Number <br /> INSTRUCTIONS ON BACK [Coifrt#Cts IifIfriEt C � Aid P k E 11 620II1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />