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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWM of 81(New Survey Form - Page 8 - 0 2 5 $ 2 0 <br /> CIWMB181{New nage <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR R BLA_C_K INK PEN <br /> Business Profile f Inspection Details <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix: I® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` !Inspected By Inspector <br /> ' f � p(! ` <br /> Physics Ad.-dress cl d 1 �V_CA-Vv� � L <br /> � � S Z � Inspection Date p I 1 � l b `�r✓ o <br /> Time In Time Out <br /> Business Rep Title 1 O AM 0 AM <br /> ` <br /> LL� � U11�-UV�w Y Com. 0 PM O PPM 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 /> Q Active i Q Passenger +I' ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauer ® Indoor <br /> O Q Inactive pJ Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATQ.. <br /> V1 HAULING AND MANIFEST REQUIREMENTS Q NOV"Of:Vlolatlotr <br /> PRC§42951-Waste Tfre Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 � Compllar�ce Deatillna <br /> Q Q PRC§42956-RegistfationlDecal in Vehicle <br /> Q ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I rn I <br /> Q Q i 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 das (Requrred fEfrNOV1 '�'> <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers I RetarretfflWylkR i� ij �//' <br /> Q O ! 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facifitfes ' ;�' <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments �L7 �.1 S 1,� l 11 5 �ot.(ivLt, w L t k 5 VLO �7 �lM uLW t- t I Ir rs <br /> �- t\k j5 V\' <br /> 4.C- V-1-C i rk Qi'C. � k6l t,i,i L>bi,'70,r-c <br /> Inspection Form Included: Q <br /> Comments Included: Q - - <br /> ,sines,Rep'�Slgtrap' Phone Number` I pector's Signa re Phone Number <br /> INSTRUCTIONS ON BACK ,Correat:io -lhcotract � (�1`v- 1 E �4 P (� t 3 s2oa1 <br /> Entered White Copy:CIWMB Yellow Copy:Operator Pink Copy:LLA y <br /> KS <br />