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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> ClWM8f 81(Nrnla survey Form Page 1 ! 4 1 $ 0 7 $ <br /> CIWMB 1B1(New nage Y g r <br /> California Integrated Waste Management Board �J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> !Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: j © 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t0�Ch� CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> ��41�1A/Y� V♦N y <br /> Business or Facility Name / <br /> nn Inspected By Inspector <br /> Physical Address 3 L ) r <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 9 00 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active • Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 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 /> Service Station C) Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT OTATtt$ <br /> V =A HAULING AND MAN FEST REQUIREMENTS �e Natioa:Q# ul¢Igtlan Q-; t�netarf <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Cgmpllan4(}ItI <br /> 0 0 PRC§42956-Registration/Decal in Vehicle n <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Onto <br /> 0 0 14 CCR.§18459.1 (a)(b)(c)-Tire Program tD Number from CIWMB v f <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RBQtllft9q/pt�Af <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Rel. FOS f� I f f l4f y <br /> 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ; <br /> Otter: is i{,:;•,�,%..i/-.�� <br /> Comments r': _.. / � L� �+L'-} ('(c-/�Vc�.l f 5 �l'C�--1✓�c� cep <br /> _1h_/15 �t 41-z- �I.-� lee-"4 V11_5G J k-e{�l �'a J I 'y t-4 61nt�t J <br /> / - k,ez ve- -- 10 �.a•�f�,.- t�.�ue. <br /> ,Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number ansis Signa r Phone Number <br /> INSTRUCTIONS ON BACK Cir t: comet ( v1 -N, P Fir ' T y [2 3 62081 <br /> _ _- -__ <br /> White Copy: IWMB Yellow Copy:Operator Pink Copy:LEA <br />