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=LE;_ Waste Tire St -ey & Inspection Repor Inspection Report Number <br /> X114- State of California <br /> Cgrated Waste <br /> Survey Form - Page 1 ! 7 - 1 0 2 5 7 4 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � � _ O � Inspection Type (Fill one) <br /> Site Suffix: Il 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> I Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> i <br /> Business or Facility Name �1 Inspected By Inspector <br /> Physical Address <br /> Inspection Date (� � I 0 165/ <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> 0 PM 0 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 /> v <br /> 4W Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ' 0 Indoor <br /> O <br /> Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 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 /> 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- <br /> STATUS.; <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Vlolation 0 Extension. <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956- Registration/Decal in Vehicle m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWML I 1 I <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requhed forNA�%OrEX7f; <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years a / <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!ClWMIV EtnfOr eMiidtlt <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators / <br /> to Compliance NO.-MO-14ltj,✓, <br /> 010 - t <br /> /Y <br /> Other: § <br /> Comments �.�� 5 A <br /> `f 1/W`.7 x t�c � ,�o �C� o-� /C>w"�� - +� L-e�cr►1- <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature f Phone Number ss! Phone Number <br /> _T.-._ . <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' ( A P ! � 62081 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />