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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CWMBgrate 18asteManage) Survey Form - Page 1 i 1 - 1 0 0 6 31 0 <br /> California Integrated Waste Management board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> !Business Profile = i Inspection Details <br /> Tplp. � � � l � j � � - � � Inspection Type (Fill one) <br /> Site Suffix: f • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �11�•{1 L �^(Cj Lt('� �(,t{r 10 CHP Q CfWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f Inspected By Inspector <br /> I Physical Address I <br /> f� f� ���t Rut( Z <br /> ; E ; Inspection!)atesc j Ca- q53 �G <br /> Time In Time Out <br /> ! Business Rep Title (� I O AM O AM <br /> vlc OSE { 1 o0, k F 4el ev— I O PM O PM <br /> r 1 <br /> Operational status i Tire Type Business Role I Storage Type <br /> 5 <br /> lire Gaunt(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a f ® Active Q Passenger ® Generator ®Outdoor <br /> I Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> a I Q Inactive ®Truck t <br /> Q Planned Q OTR <br /> Longitude - t Q End-Use Q Container <br /> I i I j <br /> Business Type (Fill all that apply) Ii <br /> Q New Tire Dealer Q Auto Repair ® 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 /> I L <br /> Q Service station Q Hauler Q Agriculture Q Shredder 0 Other Re_,_f rfuc.k tSe.rvic.Q, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility INFQRCE.. ENT STATUS..._ <br /> I y` q. HAULIN, AND*ANII=E TER �,1�}1REMENTS I <br /> O j Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Q Extension <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> I � § 9 � Compifanca Deadline <br /> Q O 'PRC§42956-Registration/Decal in Vehicle i <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements i Date / / m <br /> O O ' 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q ( Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I (Rd idled for NOV or EXT) <br /> Q Q 114 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ! Q t.4ferre .1 tMM13 Enforcemont <br /> Q Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Faciiitles I __ <br /> Y <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ( _ <br /> (n',D#itrt #I"an� 'Nq Vicl+tlona — -J <br /> Comments kotJik1e (kSp�ectcm Fae 1i'f-y Q512S LeR-'5 S&-1);LT- S1r'eet- f`errtlle <br /> V4/a5 2 �-ir� li'1 vices vi-tw� I,yO Vl re est � rcf-a•'r✓l ecpre5 op )'yta!�frr�sfs <br /> For- fiyez veav-s on —Fa c4i t s i to r �V'eabl_e 6-redo wfi'a avid oti-Sc:4 <br /> (Inspect[on Form included: Q+ <br /> Comments Included: QI LJ�lt �' ^ V `�✓ Z"i iV �`f ������"7" j <br /> I Business a 's Signature Phone Number I ctor's f ature Phone Number <br /> INSTRUCTIONS ON BACK I C0:1784'�� Eftt#;ii�l9 ,, s ) V ,I��rrl'11 P L� _If' 2 3] 62081 <br /> IWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />