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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CWMB grated Waste <br /> eManage) Survey Form - Page 1 1 5 . 1 0 2 5 81 8 <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) f+ <br /> Site Suffix: 2 �} ' O 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 <br /> Inspected By Inspector <br /> a-r' pp <br /> Ph slcai Addres <br /> 5� <br /> Inspection Date I I r> <br /> � c�0 � 1 <br /> Time In Time Ou <br /> Business Rep Title C) AM AM <br /> 1 <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> "fire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)I <br /> f f \ ® Active Q Passenger ® Generator , ® Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive � ® Truck <br /> Longitude - O End-Use i Q Container <br /> Q Planned Q OTR <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 f <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 ® Otherut� N�-t.C.- <br /> Part S- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> Vil A I HAULING AND MANIFEST REQUIREMENTS Q Notice 17f Violation, Q F_xt�ngJAn <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deddllne <br /> O Q PRC§42956-Registration/Decal in Vehicle { <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date I I <br /> O O 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m <br /> (Requ(red t'or <br /> O O , 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> NOV arT? <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i <br /> h4 <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CCIWMB Enforaetrt <br /> O O 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators , <br /> O � § Y q ' ®1n ComRllarfa� •fJa �E�rA����y�� <br /> 10 Other, § -�- y— - 1��, - _. + Q _ ,y.�,•�.•�.:/�� <br /> Comments _YJ o tC.C- �/L'`�-Cl�.�(-�• � �t��5 pl (/�W� li-� �. <br /> lw <br /> �tv� SA,-4-t%-i,�„V4�u <br /> inspection Form Included: Q (� C <br /> Comments Included: Q' <br /> Business Rep's Signature Phone Number Inspe tor's Signat Phone Number <br /> IN NS ON BACK 'Correct: Incorrect: ' EX A p , L7 3 62081 <br /> -- _ . <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />