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go <br /> Waste Tire Survey & Inspection Report Inspection Report NumberSlate of CaliforniaCIWMa181New g) Survey Form - Page 1 f 5 - 1 0 2 5 7 8 4 <br /> California Integrated Waste Management Hoard <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - O Inspection Type (Fill one) <br /> Site Suffix: `� rf / O Routine O Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP ® CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 1qo 1-6 <br /> Physical Address <br /> 301 1 �'j tote, �1�/f- <br /> Inspection Date 1 Q (� <br /> Time In Time Out <br /> Business Rep / Title�'`� O AM Q AM <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 /> ®Active A Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> O Q Inactive O Truck <br /> Longitude — O Planned Q OTR O End-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 Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ® Service Station O Hauler Q Agriculture Q Shredder Q Other <br /> _ � �,..,T N�i'��Violation <br /> Y rt A - Inspection <br /> AND MANIFEST REQUlREMENTgtor, Hauler and End-Use Facility � ENF R AMEN'$". _ <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O on O Extension <br /> Q I O PRC§42953-Contracts with Registered Waste Tire Haulers. Corlbglincj Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> rn <br /> O O : 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements patg I I I I I m <br /> Q O 14 CCR§1B459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days Rt qulred fdr NOV or EXT-) <br /> _ . ............... <br /> O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r..; i <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers . IWMo Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities s ' _ <br /> O O !14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O I �ignt:a Na Violations <br /> Other: § y 9> <br /> Comments {{ -_ <br /> �'T"G�� L�t�'-S �f v�s�v,..�z_ � tie.. 1� c�jzl-S �.�f^t->c �✓� <br /> .Ey., vy-- - -:✓e{-- (�,J�'►�7 T/. 5 G '� Iwo <br /> q <br /> . _ ��-.Fi �'�Ir7(� �✓!�Jt"/ �� �i��$ \..C�l N� "\�`~lam� '� �.:�4r�'L•.0 �Y.�j <br /> Inspection Form Included; Q 20`t5 <br /> Comments Included: <br /> Bu s ep's Signature Phone Number I ector's Signa ure Phone Number <br /> r 62081 <br /> INSTRUCTIONS ON BACK i Corroc#:* orsi:� NJ' 1FI1� `^ri �3� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />