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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> CIVVStateM Survey Form - Page 1 1 3 - 10 0 6 6 6 1 <br /> CIWMa 1B1(New 04/04) <br /> California Integrated Waste Mann9emont Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / - ® / Inspection Type (Fill one) <br /> Site Suffix; / y 3 p y 0 Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: YG0r_ 4Q¢cc,`j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name CC��--- — - - <br /> ��� Inspected By Inspector <br /> Physical Address o <br /> 69 Inspection Date <br /> Time In I Time Out <br /> Business Rep � ��we C Title : _g--D •AM 2 /� *AM <br /> 4-10-0- /4/ Wdcee O PM O lJ 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 /> ' Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O •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 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 /> r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder •Other �h r e y¢..rt r..lr� 6 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF{ EMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS _ <br /> — O Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q I Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> I <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements {jage%I )I f <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIW MB L�L JJ <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days rf?elfuuerlfdr{Y$7G-ork7) _- <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 Referred/CIWMB Enforpemg <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 /> In Compliance • tuo Vlolattotl <br /> Q Q Other: § _ na <br /> Comments /rLL!°��i' WeaC4 xLa?C jeev Gtr X-10'ric S �� <br /> Kco�'t .- 9lor�y� ,�t�/-�R� S�iI'4! a�t �i.�•d� �� 1�4.�. �d� <br /> co <br /> Inspection Form, Included:Q <br /> Comments Included:Q A -� �- � If <br /> Business RepV Signature Phone Number Inspector's Signature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK .I E X IM IM P 1 2 3 <br /> ■ 15'x' ( F — — ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0628404.0076 <br />