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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callforma <br /> CIWMB 181(New 1Survey Form - Page 1 1 5 - 1 41 4 7 9 5 <br /> California Integrated Waste Management Board <br /> Part A-1Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- -7 Inspection Type (Fill one) <br /> Site Suffix: / - d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �.� I If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Fducational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1_ w <br /> Physical Address <br /> Inspection Date O `7 I O S <br /> O•+t Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <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 /> Q Active Q Passenger Q Generator : Q Outdoor <br /> O is Closed Q Altered <br /> GPS Latitude Q Hauer Q Indoor <br /> O 0 inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 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 �I�N_F(1RCEMENT.,STATUS_. <br /> uA HAULfNQ:ANO..MANIfI�ST 12EQUtFtIaM$NT$ Q N0.11cm Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> — - <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compllanee Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements I Date <br /> Q Q 114 CCR§ 18459.1 (a)(b)(c) -Tire Program ID Number from CIWMB w w <br /> Q 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days f (Rsquk,ed for NOV or EX7) <br /> Q 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years =w _ <br /> 0 0 14 CCR§ 18461].2 Manifest System Requirements for Registered Waste Tire Haulers { � 911!CIINMI3 Enforce$ent <br /> Q Q 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 1fnlo,tf Netlol* �� <br /> 0 0 Other: § --- <br /> Comments ci.Av-rl-_4- Q ev2.do, !T-(' <br /> i-ie.*wooeJ ci4 - �-t' -�1'1`,� A)J <br /> Inspection Form Included: 0� <br /> Comments Included: * <br /> j Business Rep's Signature Phone Number or s Sign ure Phone Number <br /> INSTRUCTIONS ON BACK CorrC ;;iniFrt ,i 62081 <br /> I _ _ x( i^► <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />