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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ofCalifornia <br /> Survey Form - Page 1 1 9 - 1 0 2 5 8 5 4 <br /> CIWMB 181 stew nage y ('� <br /> California integrated Waete Management Board ) `� <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 18usiness Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: © t • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local y If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v <br /> Inspected By Inspector <br /> �'*? 1 � <br /> �Pjlcal LA4 1 3 -/ I ( ��,,ti�,� �j• s <br /> � ��� Inspection Date d '3 / 0 C? / <br /> Time In Time Out S <br /> Business Rep Title Q AM Q AM <br /> D� � QPM QPM <br /> r h� <br /> �I F_� 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 /> 1 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> DClosed 0 Altered <br /> GPS Latitude 9 Hauler 0 Indoor <br /> O 0 inactive 0 Truck <br /> Longitude - + 0 Planned 0 OTR 0 End-Use 0 Container <br /> I i <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _ENFORCEMENT STATUS <br /> H tlk'114 A[�1tZ M�kNIt��T RE�4JIF�CI�ll�laf`f� <br /> 0 0 'PRC§42951 -Waste Tire Hauler Registration and Transport of Tires #ll�ltlo�dt'VlQlittlori 0 Extension ' <br /> 0 0 i PRC§42953-Contracts with Registered Waste Tire Haulers. `Oarrlpilatice Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 - Responsible Entities Complyingwith Manifesting Requirements <br /> 0 0 [Tate / m <br /> / <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (1�6quir>9d for NOV or <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ,�F � := roMrttiM. <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities x r <br /> �' ♦ N - 3 .t £fi.ri .. <br /> 0 0 (14 CCR§ 18862 Manifest System Requirements for Tire Dealers or Waste Tiro Generatorsv r <br /> 0 0 Other: <br /> Comments <br /> r 51� ��-- ���. G ti� �.-,I� ti�4- <br /> or-*4la--5. �nv r� v,-�'� J ar•. Mh�/w- br a�._._. —7' � <br /> �•a�(e� <br /> (��'�C � 1!].�a�T -. L��a�n(s e.b►s'�"� —T%,^G.s. 1ylJ 1.•�!�- -T7►�e. _ �1w•,T+b••y aT' -Tlni's��lls��r'�.. ��// <br /> 'Inspection Form Included: 0. <br /> Comments Included: 0 - al(reY �-3b1g /��•r„^ <br /> Business Rep's Signature Phone Number 19 Phone Number <br /> sr 4/ + ( t —r— 62081 <br /> INSTRUCTIONS ON BACK `I `Nt�P L E` — Z 3 <br /> I .�.. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:SEA <br />