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is Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> reg <br /> Stateof California <br /> CIWMB 181( egSurvey Form - Page 1 1 4 - 1 0 0 5 3 0 5 <br /> California Integrated Waste Management <br /> Managee ment Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral a Observation <br /> Local !If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> QA <br /> Business or Facility Name _ —!/� Inspected By Inspector <br /> Phyyy "al AN <br /> ss rrl�ro REPS 1R <br /> l`t 0 - 60 n St <br /> Inspection Date O /„ / h "1 1 O s <br /> hbC�kfio r, C4 q,S 20q tt1 V <br /> Time In Time Out <br /> Business Rep Title OAM Q AM <br /> V Qq h X�iO PM O PM <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) t t <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> O t@1 Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> I <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT <br /> _.._ .._ .... ._ ._...._...... ........ <br /> WI: A I HAULING ND MANIFEST REQUIREMENTS _ <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice of iglatlon Q Extension <br /> Q Q i PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q i PRC§42956-Registration/Decal in Vehicle <br /> Q Q 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date) i m I / m / m <br /> Q Q ! 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I I I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and The Trip Logs within 90 days <br /> (Req u d for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460,2-Manifest System Requirements for Registered Waste Tire Haulers Q`Ref erro 1 1WMe enforcement <br /> Q Q 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q in Cattfl ae Na Vlolatlane <br /> Q Q Other: <br /> Comments FSI f t-y dogs mi& qmo-a � Wot&'f , `' s - A// C4LI1l z, yam( rt)Q t►-S <br /> are eii jin e, 4Y-aism r s5 i o vi/ C Ad. -0xA_ w&t 5y S fZt'LtS , <br /> Inspection Form Included: Q' qq*l—/ 3?7 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number I p tar's i nature Phone Number <br /> INSTRUCTIONS ON BACK .C+�rr lit. In �ir�#ctt� s2oe1 <br /> - _ <br /> A� 1:P! El 1'2 3J <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />