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Waste Tire Surve a ion Re o <br /> 11. Inspection Report Number <br /> ' 11 y & Ins pct p <br /> O��- State of California Survey Form - Page 1 1 7 - 1 0 D $ 4 7 2 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- O� O Inspection Type (Fill one) <br /> Site Suffix: ( O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SSV r_`�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T'5 W <")Physical Address <br /> Address <br /> C� 1 t (J � <br /> �AN r lA. l A' <br /> Inspection Date O .1, I f I !J <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> +QPM QPM <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 /> f 0 Active Q Passenger Q Generator Q Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> p Q Inactive Q Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other Ur���`� <br /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFI�RDMENT STATUS <br /> V ,'q HAIJURG AND MANIFUT-REQUIREMENTS <br /> Q Notice Of.Violation Q E*eHalon <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C.grnplhtr7Ca.Deadline <br /> Q Q PRC§42956-RegistrationfDecal in Vehicle <br /> Q Q 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirementsstq I I <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I 1 <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or F <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste The Haulers Retalired l CIWME EMarcipent <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 <br /> - <br /> Q Q Other: § <br /> Comments <br /> Iv�rT� �'�l/`�+t. �S e��C.. t{/�� /�►O�I p V�6C�d�-: <br /> ,Inspection Form Included: Q <br /> Comments Included: Q - - <br /> u nese Rep's Signature Phgne Number ecto ' nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON'BACK Cvh[ t: s P �. 12 3 <br /> While Copy:COMB Yellow Copy:Operator Pink Copy:LEA <br />