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Waste Tire Su.vey & Inspection Repol _ Inspection Report Number <br /> State of California <br /> Cgrated 1steM nage survey Form - Page 1 1 4 - 1 0 1 4 8 9 3 <br /> California Integrated Waste Management Board <br /> Pas{A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 7i- r f 10 Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local ( � If Referral,choose referral type(Fill one) <br /> Identifier: V1%1O� tnl1. Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical!Address <br /> P © moi z � <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep y� Title OAM O AM <br /> O PM O PM 1 <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) l *� <br /> y e Active Q Passenger 0 Generator Q Outdoor <br /> C Q Closed Q Altered f <br /> �7PS Latitude � Hauler Q Indoor <br /> C Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR O End-Use i Container I+ <br /> Business Type (Fill all that apply) f <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer O 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 ' ENFORCEMENT STATUS <br /> V, A _ HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of TireslSt3t18IA[}, <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. I CampiianCe Aeddlln6 , <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements I Data I. o s <br /> O i O14 CCR§18459.1 (a)(b)(c)-Tire Program D Number from CIWMB <br /> k (Raqulrl�d f,7r 1V�Vtsr `�}" ' <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days '„r <br /> O O 14 CCR§ 16459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years { <br /> Q Itfsfelxed!CIlNM6 Errf�tttft 3 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste lire Haulers <br /> Q O i 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> .moi <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �R <br /> O__j Q Other: § <br /> Comments A6. <br /> Inspection Form Included: Q /�� ,-,,w, �jy0� <br /> Comments Included: 04 e '-' ��� - - - ^? - <br /> B siness Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct. 111CQfreCt: 1 <br /> I: A M P L E 1 2 3 62081 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />