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Waste Tire Survey & Inspection Report Inspection Report Number <br /> 'LIp1- Stale B California Survey Form - Page 1 { 7 - 10 2 5 5 7 0 <br /> CIWMB 181(New nage y <br /> California <br /> in <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details 1 <br /> TPID- 1 h Inspection Type (Fill one) j <br /> Site Suffix: I 3 f V (S Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: Sao, 'TRA � Cp t,�yLit j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ! <br /> ' Inspected By Inspector <br /> Physical Address r3 0 1 TeKni AutiZ. <br /> St � Inspection Date 0 C, I p `3 � o ,S <br /> Time In Time Out <br /> Business Rep [r Title O AM O AM <br /> Nv� �aY�Iic'kae-` MaiKte31 .'u ML9r" O PM O PM <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 /> t ® Active Q Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® 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 ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other T►�Lt,C,�. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V:1 A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extenslcm <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m m <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q ( Q 14 CCR§ 16459.1 (a)(b)(cl- Trre Program 10 Number from C1>WM.9 <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required 6.rNS3�JOr&3{7;` <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I COMB.- <br /> 0 <br /> OMB Q O 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 <br /> §Q Q Other: <br /> Comments PeCF' Tire- - ��a�Np� Tife rGM�s wasfe r freesc -f ✓2.sar%ruy�'aX' <br /> 2,x mo k-+k- j ' eSfi S ✓i e i eo, t•_pcrti-, <br /> oh � <br /> Inspection Form Included: O � Ali <br /> Gamms»ts 1ncJuded; ure Phone NumberB sines Reps Signature Phone Number INSTR CTIONS ON BACK Correct:+ Incorrect:� (k 1 Z 3 s2os1 <br /> Ent+area - ll _. <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LI_A <br />