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Waste Tire Survey & Inspection Report Inspection Report Number <br /> >,k SlWMBali(ornla Survey Form - Page 1 I 7 - 1025646 <br /> CIWMB 1ate of 1B1(New 04!04) <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ _ I Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix; l r J'Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: &rl �� O�q t�l�l Y-1 coW IA,I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Tr Y,&kina <br /> Physical A dress '1 9 <br /> 2-LIo <br /> Sty inspection Date D / � <br /> I O ' <br /> �f I <br /> Time In Time Out <br /> Business Rep )+ Title 0 AM 0 AM <br /> �f)jjGOQllaiij 0(�, 11ev- 0PM 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR O End-Use ® 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 I ENFORCEM I�4T STATU$ <br /> _ - r <br /> V; A► : HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q$xY 4f�lis� <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. CompllilrlCH Deadilne <br /> Q Q I PRC§42956-Registration/Decal in Vehicle m m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data I I III f f f <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> {Rec�u d far wV gr <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O+teflarrS 1 t;11tYilf>� f (���llf% <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators s yam/ii <br /> Other: § p� ,Ia_�_ <br /> Comments�IaSte fi i Vt��� J�' J iM JA Cf D 601C(tK p �/til�t��S . VieVJ4 <br /> V�.c h� _ Pests (C'"4i- Z00S"-pl V8 . l es St reA rh 't►`ik ` ee- <br /> akct t^,ewved aba lL+ alice ,et�,ery 6w m a ltif4 s. pew rAaptz fesis <br /> --- <br /> Inspection Form Included: Q <br /> Comments Included: - <br /> Q 1 es Signature Phone Number pecto ignature Phone Number <br /> _ — <br /> � 62081 <br /> INSTRU549%CbN BAC Co"Get:o Incorirect. ( J AMP L i ' 12 <br /> KB11_ -- —--- <br /> White Copp y::CIWMB Yellow Copy:Operator Pink Copy:LEA <br />