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� Waste Tire Sui y & inspection Report nspection Report Number <br /> i)< State B California I 1 - 1140581 <br /> CIWMB 161(New <br /> Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A--Survey---- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ / - Inspection Type (Fill one) <br /> Site Suffix: 2— ;_ ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ✓ - <br /> Inspected By Inspector <br /> I <br /> Physicald� <br /> /as v � , <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM 01M <br /> ` O PM PM <br /> - Vis ----- ---1- - � <br /> I IV S O ! Storage-Type <br /> I StatusTire <br /> BIole <br /> (Filloneonly) (Fill at apply) ( II all that apply) (Fill althat appl <br /> v) <br /> Tire Count(Whole/PTE) <br /> 0 Active 0 Passenger ®Generator 0 Outdoor i <br /> Latitude O 0 Closed 0 Altered <br /> e <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use ® Container <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 /> i <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Othery � sS <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCFMENT$-TATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Notice' <br /> 'Viola#inti �'ExtensioW <br /> 0 1 0 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 i § 9 Compliance Deadline 1 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /.m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> I <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities x5 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> �"�'� r �. <br /> �a[�� ��II��i1t�e � M�c� liola€FtTnr <br /> 0 0 Other: § W __ <br /> Comments <br /> Inspection Form Included: 0 <br /> CZE i 4��� ~ z <br /> Comments Included: - -- - - -- --- - <br /> Busines ep's Signatur Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Coitetti +orrect� A 62os1 <br /> Yellow <br /> ... <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />