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i <br /> = n, Waste Tire Survey & Inspection Report Inspection Report Number <br /> -- S=ate of California <br /> CIWMBtedW Waste <br /> eManage) Survey Form - Page 1 f 1 - 1 0 2 5 1 4 <br /> California Integrated Weate Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: C5 ( I Q Routine # Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I r <br /> Physi at Address I - I L> 1 �-G �.(,j-a�t, <br /> S 3 7 �--..� S �-LL�(� !a'lr-L I� <br /> Inspection Date C> D U ST <br /> 3t>A I <br /> Time In Time Out <br /> Business Rep p� Title O AM O AM <br /> S 11�^ t `� j/y� _ O PM O PM <br /> I <br /> .D <br /> - Q Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) <br /> I(Fill one only) I (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> � � '�. � I <br /> ®Active I Q Passenger Generator Q Outdoor <br /> GPS Latitude D I Q Closed Q Altered <br /> f Q Hauler Q Indoor <br /> D � Q Inactive ®Truck <br /> Longitude IQ Planned Q OTR I 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 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility 1 I ENFOR"'C��`E"`M"NEN"`T"'S��STATUS <br /> 11`14UL1NG J"D 04NIFEST REQUIRSM NTS. f Q.Notice of Vblgttort Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i .PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 Compliance Dead-line <br /> Q Q (PRC§42956-Registration/Decal in Vehicle <br /> O 0 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ( M /.E] / M <br /> Q IQ 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB i <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requir*d IW'NOV or En <br /> O . O <br /> 114 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 1 Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q dOrfftdi Of" Enforcement � <br /> 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O I O <br /> Q 10 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> p ' p i Other: §�uxC 3 -L1�_ l u�- ._ �ov»rN a.. 1la1i - No VIQItN4 t <br /> Comments L• (�v�",t✓. M W►+� }�TS��S 1�V'tins u��,�- i�'tb� , � pa� " �.Q:-(.r�.�� l <br /> `co r (7 r(;�•u..P wc�.Cr i i'f-�56 1-��f f(�rr..�.� �! �r �7 s���sa� . W r.�'..t..�. <br /> y 1vQ �plt"E'�`'1` W` ii. � �lt vY� CY 1r } • � �p� �'I�WI�C� r <br /> 4LV r c 4n_ E � <br /> Inspection Form Included: Q <br /> Comments Included: "�l b <br /> 4ssps Signature Phone Numbe`r� (� inks tor's Signature Phone Number <br /> � <br /> INSTRUCTIONS ON BACK iPf l � yr f' {Vt L�'Xj APPE_ t 2 3 d <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />