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6r Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r� <br /> State or181(New Survey Form - Page 1 1 2 - 1 0 1 3 1 4 2 <br /> CIWMB iB1(New nag4) <br /> Califomie Integrated Waste Management Board <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Suffix:Site > j O S S_ - �� <br /> _ ®Routine Q Re-inspection Q Referral Q Observation <br /> Local (� / If Referral,choose referral type(Fill one) <br /> Identifier: G+y2 C pG��H (-�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> I ` Inspected By Inspector <br /> 9 - sf k-I <br /> Physical) Address 3 p Al <br /> /3d31) <br /> Inspection Date / „ - C / C L <br /> Time In Time Out <br /> Business Rep Title AM 0 AM <br /> 0 PM 0 PM <br /> -�cs-,%f ��i�rrl%✓fit _ _ <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S' Q <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q Passenger •Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> O QInactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> _ 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 E114Ft3RCf MENTSIA7US <br /> HAULING AND M1iNIfE§T REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler lt,,p,tralion and Transport of Tires C,)Nonce Of Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle l r <br /> I E] <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 (iie4un pPorThJtto Fx7) <br /> Q Q 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 t9itT <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities - <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators - = "'' <br /> Q QOther: § .w <br /> ,W Li <br /> Bae z <br /> Comments c fti J` L�� �4sB' 7uE L��fkdi :e-<y <br /> .y <br /> Inspection Form Included:Q <br /> Comments Included:Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK �t <br /> 6I EMAMPLLE13 62081® ■ <br /> White Copy:CIWMB veilnw Copy:Operator Pink Copy:LEA <br /> 0703804.0494 <br />