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E_ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Survey Form - Page 1 1 4 . 1 0 1 3 4 4 5 <br /> CIWMBB181(New 04/04) <br /> Callfomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- t—r 1. - O Inspection Type (Fill one) — -- <br /> Slte Suffix: J "t 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - <br /> Inspected By Inspector <br /> Ph dd Iy 0 39 <br /> Pd <br /> S4ocibl/ n �­-T IS <br /> Inspection Date C ! (j O <br /> Time In Time Out/ <br /> Business Rep Title OAM O AM <br /> PM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active Q Passenger ®Generator 0 Outdoor IA O 0 Closed 0 AlteredlI <br /> GPS Latitude Q Hauler 0 Indoor P <br /> 0 Q Inactive ®Truck <br /> Longitude - 0 Planned It OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair ®Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Furl <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture 0 Shredder ®Other <br /> l _ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility `ENFURCEf+IEE13TSTA I US <br /> Notice Of Violation 0 Extension <br /> 0 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate ITI /LL]Q0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB i f <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days (RegpkadjixNOVor FX 77) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 CIWMB Enforcement <br /> 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 /> in Compfaartce - No Violations <br /> Q Q Other: § - - <br /> Comments0 <br /> I - -h <br /> ,Inspection Form Included:Q �/J +SIur <br /> Sq <br /> -Z�,-kz <br /> Comments Included:Q - —siness Rep Signature Phone Number In toe _ Phone Number <br /> INSTRUCTIONS ON BACK I E!sX[AlIMI P I L I El I 1 I2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA © . <br /> F.1 h,'4'R4.kitb` <br />