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U11 <br /> Waste Tire Su 3y & Inspection Repor� Inspection Report Number <br /> 10 StateotCallow 0 ■ <br /> CIWMB 181(New Survey Form - Page 1 f 8 10 2 5 8 4 0 <br /> 4104) <br /> callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspectlon Details <br /> TPID- ` _ Inspection Type (Fill one) <br /> Site Suffix: ` Q ® Routine 0 Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical A4&ess 7J' - ` Q <br /> Inspection Date D <br /> v�� v Time In Time Out <br /> +Business Rep Title O AM O AM <br /> O PM 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 /> 1 ' # Active ® Passenger 0 Generator ® Outdoor <br /> I <br /> O O Closed 0 Altered <br /> GPS latitude 0Hauler Olndoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body O Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN?9Rf; MENT STATUS _!` <br /> V -A: HA 0 QNQ.AND MA NtF.P9T RE'sQyJREMI N' w Q Natlati Of Violation O Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires j <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers, GArnpliaitGa'_I�sadllne <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(o)-Tire Program ID Number from CIWMB I w <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Ra9Ulrod for NOV or SM <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 ( ,I� iB�PQd R1�i1fNIE` -Enfgrcem�nt <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 <br /> O O 60-0 ► R No Yl0latltlq* .__ <br /> Other: § t ;y, <br /> Comments {tom oq�s b lJ� ��t pl nt 11Y v "Are— <br /> LV <br /> Are-L.r <br /> Ct <br /> ,Inspection Form Included: <br /> Comments Included: Cc, ! <br /> s Rep's Signature Phone Numbers Ins ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK �` �rr� � 1tCh�t,c� .' � ��/1 LA�.Ihrt lI TIL 620II1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />