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Waste Tire Sufty & Inspection Report Inspection Report Number <br /> State ofCalifornia Survey Form - Page 1 1 3 - 1 Q 2 5 i 2 5 <br /> CIWMB 101 thew 04104) <br /> Callfornla Integrated Waste Management Board <br /> Part A. Survpy BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- tion Inspection Type (Fill one) <br /> Site Suffix: ? ,40 Routine Q Re-inspection Q Referral 0 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 /> Physical Address <br /> Inspection Date <br /> 613 / d a I Q T <br /> Time Out <br /> Business Rep Title Time In 0 AM O AM <br /> U 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 /> O ® Active Q Passenger ! Generator 0 Outdoor <br /> O O Closed Q Altered <br /> Gp$ Latitude Q Hauler 'i 0 Indoor <br /> O Inactive 0 Truck <br /> Longitude Q End-Use Q Container <br /> Planned <br /> OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A► : RAIftl i�tA1 11 1!11Rlot' #E£�tJl6tl"MEN'I'EI. <br /> 0Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires O NOtIa.Oi Violation Q Bxtsnelon <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O �stmpl#en�a Rtlladiiga <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pita <br /> O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMI3 I I { <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days t $0. 4IOid.lbrNOVoc XT} <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers � i�tf4rr�d'1�11�11f�6 Et1fQr4Wllfnt ' <br /> O 0 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators z � olatl+ n <br /> Y <br /> 0 j O Other: -- <br /> Comments o�Y/� .. +`�l�S �'�-L-• -- -- <br /> !�/..it�el�� �s a d / ��e �e anV va ��t>«r <br /> Qom- <br /> �'l a•tit/ °iGKo�cr �����8 ��I13,'�f <br /> // v <br /> Gt C/if C-aa l`,W l t V-a �I'//, �.�j X76 ��( l rf z✓/5�`e! 50- <br /> Inspection Form Included: Q <br /> Comments Included: Q r S3 76� <br /> BusinessRe�ature Phone Number s s Signatur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKS1it'f ;) � f A� �P � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:L.EA <br />