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�!tata��llfote Tire Survey & Inspection Report Inspection Report Number <br /> rnla <br /> Cgrated Waste <br /> Survey Form - Page 1 1 6 - 1 0 2 6 7 6 9 <br /> California Integrated Wasto Management Board <br /> Part A- Survey BLUE OR BLACK INK PE.. <br /> Business Profile ,Inspection Details <br /> TPiD- Inspection Type (Fill one) <br /> Site Suffix: - 7 3 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> ID <br /> Physical Address <br /> Inspection Date d l I Drj <br /> 10t. 1�376 <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �j <br /> ® Active Q Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> p Q Inactive j 0 Truck <br /> Longitude _ Q Planned Q OTR o End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair B 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 ENFORCE_ME_T STATUS <br /> V A HAULING AID MANIFEST REQUIREMENTS P Q Notice Of VI latlon Q Extension <br /> o Q PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> o Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance De dline <br /> Q o j PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateT / m / M <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> o . 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Require for NOV or EXT) <br /> oho - <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tiro Trip Logs for 3 years i <br /> o Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers o Referred 101 . MB Enforcement <br /> I <br /> O o 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q o 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q ! Q other: § (�In Comp.11an No Violations <br /> — <br /> Comments ���'�.G_ 1����t.>7•� �15��- 1 fie_.Ko�V?��^'Mp v�-ot.'S J�� , — - - - - <br /> L QtG 1 t Y r � l VV t VSO 1^V`,,A y. 0 <br /> w+�',a ✓U�s i u�s Ok W4,2XC ���Q S a�a- L.a vt�e� 54-,Z . <br /> No V.�f� S or greel.S 11 UNccr-^ — - - <br /> Inspection Form :nc <br /> ncluded: Q n <br /> Comments luded: Q <br /> Busin s ep's Signature Phone Number Phone Number <br /> INSTRUCTIONS ON BACK CAPI9Ct; Inaorrc# ' , �/ R`- i 1- � 1 2 i 3 62081 <br /> Wh to Copy:ChAIMB Yellow Copy Operator Pink Copy:LEA <br />