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Waste Tire SuRey & Inspection Report Inspection Report Number <br /> 1111 State of California <br /> CWMB 1steManag) Survey Form - Page 1 i t - 1 0 0 5 3 0 8 <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: Routine 0 Re-inspection Q Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: `Qolty_J-00-r"t V, CC) Q CHP Q CIWMB Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> 3io S S C�fv�h a tke-e, �� <br /> IInspection Date 0 � <br /> ,SfockJvtn C A C11 z0 S" tt v �J <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1, ^� 0 PM O PM V C o}L Cmc .S IV`q r <br /> l 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 /> It 0 Active 0 Passenger lb Generator & Outdoor <br /> Q 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Wnactive ® Truck <br /> Longitude - 0 Planned 0 OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> o 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 -rte r <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 ENFORCEM„ 4T.STATUS <br /> V A HAULING ANQ MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notlae Of elation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance D adllne <br /> 0 0 I PRC§42956-Registration/Decal in Vehicle m m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0l Ill }} I I 1 <br /> 14 CCR§18459.1 (a)(!J)(c)-Tim Program{D Number from CIV'JM8 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RegUJ d for NOV orEXT) <br /> 0 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 Q R0faerred j,. 1WMI3 Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators J� <br /> Qo �h4mfA�1 oe ,.No.Violations --- <br /> Other: § <br /> Commentslryk .IIIASP Icf1Dtn faCiL+ pv-DVicl� �h�01(��s ;br 1/'—,. e-d I. o s�_ <br /> �e M a t�LLQ T t�l� Jr� J �Q✓�c'l h �v �n b►'l 1 j V I� �wll �iYe ✓�cwt.a✓cz r <br /> is �I at ts� �Inspection Form Included: 4Bsiness <br /> Comments Included: Rep's Signature Phone Number �sact'0111*11nature Phone Number <br /> INSTRUCTIONS ON BACK arrelcti InO6 i.i ti E- I_ . �L L._L 2.L3_ 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />