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ua= Waste Tire Survey & Inspection Report - Inspection Report Number <br /> e <br /> State of California <br /> CIWMB 181(Now <br /> 0004) Survey Form - Page 1 1 6 - 1006439 <br /> California Integrated Waste Management Board -. <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business pmate- Inspection a]etaUs: <br /> TPID- 1 G O ! Inspection Type (Fill one) <br /> Site Suffix: ( $ ( �' E e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP .Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> \ <br /> Physical Address ____.___..,,_.l Z c� - t I C> <br /> `t <br /> � �r�l� Inspection Date (� <br /> `7 <br /> t o+` J <br /> Time In Time Out <br /> Business Rep Title E FIM � O AM <br /> 1Ar'Y (�tftS v�WC' O PM i .. I PM <br /> -�sotn aw -- <br /> -- -- Operational Status Tire Type Business Role, Storage Type 1 <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)I <br /> 1 40 Active ®Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 Q Trucking Fleet p Government Q Retreader ®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 <br /> Part B-Inspection off.Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS T <br /> E !LF'=.,._:' -... .. - �oTtice Of Viciat o (�Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline F <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB / r <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> .g <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or-Waste Tire Generators ' <br /> Q 1 Q 1 Other: § <br /> Comments '-- -t,t_ M�v�1�1ce.SAlt!s <br /> t-0.CSkc us4S v O ��."VAa 0.4 %MA-V%TC�e� V`O�LI.IIar rLy`l.A.tAGf�- <br /> a11 <br /> 4"t C_. - - <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> &REe � - <br /> Phone Number In_ re Phone Number <br /> INSTRUCTIONS ON BACK „ O X ,I$ i. F L Ei }; i.�i 62081 <br /> E <br /> '■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> 0525804.0166 <br />