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Inspection Report Number <br /> Waste Tire Su vey & Inspection Repo <br /> State of California <br /> tWMn aaf fornix al Survey Form - Page 1 14 - 1 0 1 4 8 9 3 <br /> California Integrated Waste Management Board <br /> Pas{A- Survey BLUE OR BLACK INK_ PEN <br /> Business Profits (Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f 7 :7, 140 Routine Q Re-inspection Q Referral Q Observation <br /> 1 <br /> Local �/, If Referral,choose referral type(Fill one) <br /> Identifier: o <br /> ( .�y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Faciffty Name Y Inspected By Inspector <br /> Physicatl�Address <br /> Inspection Date <br /> Time In Time Out <br /> BusinessRep /� ' Title O AM O AM <br /> ' - / � L/ n O PM O PM <br /> �} Operational Status Tire Type Business Role Storage Type <br /> (Whole/PTE)Tire Count <br /> (Fil(one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l <br /> { e Active Q Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude a Hauler Q Indoor <br /> O Q Inactive 4@ Truck <br /> Longitude — Q Planned 00 OTR O End-Use i Container <br /> Business Type (Fill all that apply) <br /> I$ New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 8 - Inspection of Waste Tire Deafer, Generator, Hauler and End-Use Facility (_ENFORCEMENT STATUS <br /> I V; A HAULING AND MANIFEST REQUIREMENTS j Q Notice Of VlolatIon <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires IXtett�IQn" <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance rDeadlino <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements I Date <br /> 14 CCR§18459.1 a b c -Tire Program iD Number from CIWMB . <br /> (Ragt�lr9d f,7f NQU�r f� , <br /> O O 74 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days „ <br /> Q Q 14 CCR§ 18459.3 Retention of Manifest Forms and Tire Trip Logs for 3 years I r <br /> O 014 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Rahrre�I J CfS{Vfi�B E1flq�f� ; /F. <br /> O O <br /> i 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 +14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O ) <br /> Other: §__ <br /> Comments AC <br /> Inspection Form Included: Q <br /> Comments Included: 04 <br /> B siness Rep's Signature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect.,X FE >�'A, hh I P I L J EMI Z 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />