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Inspection Report Number <br /> Waste Tire Survey & Inspection ReportStale <br /> C5WM f 81(Now Survey Form Page 1 1 7 - 1 4 2 6 61 3 <br /> C{WMB 181(New 04104) n <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: 3 V C ( QP Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cw t�tr.�l r� � y 4—:-- D 0 CHP 0 CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L Inspected By Inspector <br /> 4Me-, �w 1,4 kc. 142,,5 <br /> Physical Address <br /> w��� Inspection Date <br /> CA <br /> Cjj Time in "T Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> ��c]r_�{CJ r � t�►'— 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) C� <br /> 0 Active a Passenger ID Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler II* Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 End-Use Q Container <br /> 0 Planned 0 OTR <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 y <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT-8TATUS _-....._.I <br /> HAl .1�1S31I M�kC+�1FST.lt�tJIIREMETS € Notlao Ct! Violatlort Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 1 PRC§42953-Contracts with Registered Waste Tire Haulers. QSitnpllsl�pN Rped[IRe <br /> I <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Qpt9 m / m <br /> i <br /> 0 i 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIW MB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RBpulred forNOV orEXT) <br /> 0 0 114 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r <br /> i <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers +,� C Afq r id/C1Vf/ : Enforoement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities I / <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators _ <br /> ,��� f�#��sra ;YMl�ti+9Uli <br /> 0 0 .other: § — <br /> Comments No—coy A4 jS g O,� '-�C�t,.1 r �.J�s7�i �Ir�S <br /> Inspection Form Included: 0 -2a C// <br /> Comments Included: 0 t�/jo_ <br /> Business Rep's Signature Phone Number In?AMt, <br /> Signa u 4PffNumber <br /> INSTRUCTIONS ON BACK L:Qpt '� fir 62081 <br /> " ' l. E � 1 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />