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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> r 81(Now <br /> C1WM Survey Form - Page 1 2 - 0 Z 3 3 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR R B_L_ACK INK_PEN <br /> Business Profile ;inspection Details <br /> TPID- 4 ry /+� Inspection Type (Fill one) <br /> Site Suffix: 1 l D f C/ s t� 4J Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � - If Referral,choose referral type(Fill one) <br /> Identifier: LJa L � h C�0�,/(, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> T� inspected By— J inspector <br /> A)rvm <br /> Physical Address ! ` � <br /> Inspection Date D l f <br /> �� bYl L� �� � 3 <br /> i � Time In Time Out <br /> Business Rep Title C) AM O AM <br /> 0 P 0 P <br /> ►'vt c l G_c�o Q SSoc�ra��. - I <br /> 5 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 IS Generator ® Outdoor <br /> O ! 0 Closed I 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ! 0 Truck <br /> Longitude — 0 Planned 0 OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government O Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j ENFORCEMENT'STATU&_ <br /> VA . HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PO Notice Of Vlolatlart ESttJAfl�ftl . <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. COtnpllanae D9lldline <br /> i / <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m m s ✓% <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date l I ) Ell 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program 1D Number from CIWMB � I <br /> 0 0 (iiequh�dforfVAffvt� <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ' O lR6f61f9pt!(Cfu11MB Sgft4 #r#�yilt . <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities s f <br /> 0 , 0 <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> '` /y~ � <br /> 0 O - <br /> Other: § L_� -- � <br /> Comments Uj-ewec� MCt1-'i4_SN C't Tfr2S /-Laft-.tact aq(-ojCfiv' wiJ ortC <br /> / <br /> v- YY,,,>A � ��ic � S Tre, D-c oSa, Waste kres S-for-J CL� no✓41, <br /> I <br /> W ec'e eo rkq� 4 proper-4, , �.r to a fi r� a-bi t,c.;f r,✓'•2 f✓'0 rawt w a S fat's trt <br /> a,tAd o(.�s G r t sse d , No 1e ftIl of 4k's - iWk I <br /> inspection Form Included: 0 ` � � 1 1 C!— <br /> Comments Included: l(Ott <br /> usiness Rep's Signature Phone Number In actor's Si lure Phone Number <br /> ter F_ <br /> INSTRUCTIInt�ON BACK !Correct .*° Incorkect ( Er x a M] L E t 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br />