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iL _ Waste Tire Survey & Inspection Report Inspection Report Number <br /> LUEIli State of California <br /> Ow ClW8 18104104) <br /> California Int grat d Was eeManagement Board Survey Form - Page 1 1 - 1 D 14 718 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> :Business Profile Inspection Details <br /> TPID- Inspection� � � — D � Inspection Type (Fill one) <br /> � D <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5CZ �� I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> j Business or Facility Name J <br /> Inspected By Inspector <br /> Physical Address <br /> I <br /> 1-5 ,,3 <br /> Inspection Date � t^/ / l o <br /> Time In [ Time Out <br /> j Business Rep Title i7 AM 0 AM <br /> 0 P QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) �� p <br /> &Active 0 Passenger • Generator • Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 inactive I*Truck <br /> Longitude — i 0 Planned j 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1.ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 0 Nctlaa Of VCalatl4n. C� ctertol9n <br /> 0 4 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires y <br /> 'J 0 PRC§42953-Contracts with Registered Waste Tire Haulers. COrt1pIE�pR@ At9ad11nA . <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date I I <br /> 0 + 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program 10 Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I <br /> (ROPIrod;far NAif;'er m <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 j 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 90fere6 101WMt EgfQt$�tT nt <br /> 0 { 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities no i <br /> 0 0 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators ' is <br /> Other: § <br /> 0 <br /> _ i 0 <br /> Comments <br /> rkN//1 v �(5 O �f< �,.1 Joe_ �acula <br /> a ✓ oy— 'T I A-le- <br /> Inspection <br /> Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number r nature Phone Number <br /> e 62081 <br /> INSTRUCTIONS ON BACK ' Correct:* incorrect: V (� � L � f 44 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />