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„t« <br /> Waste Tire Su 3y & Inspection Report Inspection Report Number <br /> St ate of California <br /> CIWMB 181(New 04104) Survey Form Page 1 1 6 - 1 01 4 7 4 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR_BLA_CK_INK PEN <br /> F Business Profile _ I Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 7 i®Routine Q Re-inspection Q Referral Q Observation <br /> Local j �- If Referral,choose referral type(Fill one) <br /> Identifier: � I�t,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T Inspected By Inspector <br /> PI�L /f <br /> Physica Address <br /> 572,1 QJ <br /> Inspection Date <br /> Z-0 CL <br /> Time In Time Out <br /> Business Rep Title AM O AM <br /> � O PM O PM <br /> wz..�- - -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> • 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.ST <br /> V . A HAULING AND NtANIFEST-REWUIREMENT3 <br /> Q O O ivotice:flf Vlolatian (�00 <br /> � y, <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires s <br /> i i <br /> / motif <br /> fi�i"N <br /> Q Q PRC§42953 Contracts with Registered Waste Tire Haulers. CCtnplIgnes DM-'lin$ ,y��✓% <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data / �! <br /> O 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program )D Number from CIWMB I - s.,r. •i <br /> t <br /> O Ouct=arNt�� . <br /> � 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I - �� <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 400 <br /> �” =� -y fir,: ': -ry r,"i <br /> Q O � 14 CCR§ 16461 -Manifest System Requirements for Waste Tire End-Use Facilities � v. z�> <br /> o 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> �' j L <br /> Comments J an�'�iGfITS Fes! t 5r�-�� <br /> 41-o—I <br /> c s ,�,J�`y-�.�- II �,,1a.-- - 9 <br /> l\JD vtr_71C,-hZ>t_3 <br /> Inspection Form Included: <br /> Comments Included: Q f't GOAN <br /> Business Reps Signature Phone Number Inspe o s Signature Phone Number <br /> INSTRUCTIONS ON BACK C. =Inc rr ( E X +� M P L t <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />