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Waste Tire Surly & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 1B1e ) Survey Form - Page 1 1 1 - 1 0 1 4 7 5 0 <br /> California Integrated WaststManagm <br /> Waste Manageent Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile. inspection Details <br /> �TPID- _ Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: .ty 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '� 11 ( Inspected By Inspector <br /> Physical Address <br /> Inspection Date f 2,-' <br /> j epi if I <br /> -'A Time In Time OuuttC <br /> Business Rep Title0 AM Q AM <br /> /� Q PM Q 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 /> ' ® Active ® Passenger ! Generator 46 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck I <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 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> I <br /> I 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 _ENFORC§MENT STAT�J# <br /> V HAUL NG ANG MAN) E9T REQUIREMENTS f T� <br /> Q Q j PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i Q Notice Of YIDIatIAn ntt911> on <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. CompICAf14® 13014dl(ifs <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate C) f S <br /> Q ® 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 Submittal of Manifest Forms and Tire Trip Logs within 90 days [Regt�(tHalfk?/!�}V � <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and The Trip Logs for 3 years <br /> f.. <br /> Q Q j 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q R* 00 All '� #�ftat- <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities —y.. >� _ � %' <br /> Q Q 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q O Other: § <br /> Comments 1 <br /> Ul-,Sf <br /> 115 /`�h��i✓ / - L 6i h r{ ) ' ! ' �'"" j �•�j.Yj_cf— �t{ LIZ( fO f 7-31�Lt <br /> Cab��,'� -TP JIrJ ��/5! �r.�. <br /> :Inspection Form Included: Q <br /> Comments Included: _ �! L/ <br /> Business Rep's Signatur Phone Number/ �In ctor's S19 a ure phone Number <br /> lV X I� M PT(r i r T 62081 <br /> INSTRUCTIONS ON BACK [Cocrect; - InGat��ct: (',�.-f� _�1 JI L_.l_� <br /> - White Copy,CIWMB Yellow Copy,Operator Pink Copy:LEA <br />