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Waste Tire Survey & Inspection Report Inspection Report Number <br /> EE <br /> L StataCalifornia Survey Form - Page 1 1 7 - Q 2 $ $ 3 6 <br /> CIWMB 1 a (New 04104) <br /> California Integrated edWaste Management Board <br /> Part_A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � •� - © � Inspection Type (Fill one) <br /> Site Suffix: (9 �1 # Routine Q Re-inspection Q Referral Q Observation <br /> 1 Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB 0 Complaint 0 Educational Visit O Other <br /> Business or Facility NameInspected By Inspector <br /> ` S� <br /> Ph sisal dress <br /> Inspection Date U T <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM DPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V ® Active (D Passenger 0 Generator Q Outdoor <br /> O 0 Closed 0Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - Q Planned 0 OTR O Fnd-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Yh _ H>�t:L1NQ ANt�MANII"Et3T:RE�rl1JIREONT Q Notici Of-Violation () Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 i 0 PRC§42953-Contracts with Registered Waste Tire Haulers. ;. Cgm011dnt3e'176adIIRs <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate m / m , m <br /> O Q 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 {Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -- <br /> i <br /> O 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ.,Rsi�rrl 7.01WM. Enforcement <br /> 0 Q 14 CCR§ 18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q • 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 Q Other: § ���r� ���e :h {�¢ �IQi■dp1111 ___.. <br /> Comments74 <br /> p <br /> C <br /> Inspection Form Included: Q t 11�,Z <br /> Comments Included: Q "1 7 edea <br /> Bu ess Rep's Ignature Phone Number InspeAIgnature hone Number <br /> INSTRUCTIONS ON BACK Etitt'1i1 rlt�6ti �, � �( A.�►ti�pi1E2� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />