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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stale of Californla <br /> CWMB grated Waste <br /> Survey Form - Page 1 1 9 . 1 0 2 5 0 31 <br /> California Integrated Wasto Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business_Profile Inspection Details <br /> I_TPID- Inspection!Inspection Type (Fill one) + <br /> Site Suffix. 1 I 9 O 1 i® Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> identifier: _�a-vv �1 0ol, u 0 CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� V�1 I + <br /> Inspected By Inspector <br /> Q —re <br /> Physical Addv <br /> t� RL <br /> Lti.Z- <br /> SC-� {"�!'1 �� 95a� Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title Q APA 0 AM <br /> C) PPA O PM <br /> �3 n <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 /> Active ® Passenger iffiGenerator 01,Outdoor <br /> O � Q Closed Q Altered <br /> GPS Latitude Q Hauler O indoor <br /> O Q Inactive Q Truck <br /> Longitude — 0 Planned Q OTR 10 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 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder 0 Other + <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 0§NCEM9NT:STATUS <br /> �.V_, :f HAULING AND MANIFEST REQUIREMENTS <br /> i 0.N6 a, Of Violation �< <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. 4 <br /> IIII lrprry_p(iartce Deadline <br /> Q O I PRC§42956-Registration/Decal in Vehicle m <br /> Q O 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i W1t9( I I <br /> Q 14 CCR§18459.1 (a)(b)(c)-Tire Program to Number from CIWMB `' �I II �� I L J <br /> ! (Required for NOV pr <br /> O 114 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days _ <br /> Q I 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> (D Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q E36�e1'CI III i, <br /> 0 O 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ay. , .•. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> $ v i; <br /> Other. § <br /> Comment <br /> ti a Wast.e- A es re;vLo,l-a-� 'f wo w e s � �ot�i l(� �r e. , �C <br /> p'wvil�_s-�-s . Nasf'c +re s S IVro-d `' �'? ott ci o ars ' -bi se 4,ssed �aste. re_ <br /> } pro jalm aic� gave co fles OF !m&v'ehatioei O�1r�tr �� 4%l�.ty re�a�dc` <br /> wa' <br /> .inspection Form Included: Q /� <br /> Comments Included: QI 1r � � <br /> Business Rep's Signature Phone Number Ins ctor's S nature P_h_one Number <br /> INSTRUCTIO CK Cor64dVW inicorrle�cts — E X A M P L E t 2 62081 <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA _ Iu <br />