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Waste Tire Survey & Inspection Report Inspection Report Number <br /> StateCalifornia Survey Form Page 1 I Z 1 6 2 6 7 6 5 <br /> CIWMB 181(New 04104) � <br /> California Integrateded Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site suffix: 3 8 �. G d IN Routine Q Re-inspection Q Referral Q Observation <br /> Local 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 /> vl awe Y�t,c 3 7 � D <br /> Physical Ad��s — <br /> �t- <br /> Inspection Date 05 <br /> —_.,C-4 o+^ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Q PM O PM <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 /> 40 Active Q Passenger 0 Generator 0 Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive &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 EN G MENT.$TATUS _ <br /> V- - A. I HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Oteft Violation Q Extension <br /> Q , Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Csln���ln�i [fatadtlne <br /> O Q PRC§42956-Registration/Decal in Vehicle s <br /> s <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Qe I <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I 1 1 f <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days *I I f egQked r NOV or EX7) <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years x 3 <br /> O O 14 CCR§18460.2- Manifest System Requirements for Registered Waste Tire Haulers O 8h y tI!�IwMa Enforcement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O ! 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' I <br /> II004� No Violations <br /> 000 Other: § _ r <br /> Comments <br /> �\fes v1� /; ,o'�l�st+e�- ot4�. {�.`�'► V,��-. <br /> 4X-1 <br /> Inspection Form/// Included: Q` y,_ ,'.�I Q 1,n or <br /> Comments Included: Q 'y <br /> Busmess. ep s Signature Phone Number Ins trgnature Phone Number <br /> INSTRUCTIONS ON BACK Qttl'1` +r�; Inc�arr,� t, ( � _ h;Mf f Lrt j2�3� 62111 <br /> Entered White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br /> KB <br />