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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form - Page 1 ! 7 - 1 0 1 4 8 0 5 <br /> CIWMB 181;W 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- - O Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection 0 Referral 0 Observation <br /> Local � \ !If Referral,choose referral type(Fill one) <br /> Identifier: �}�� Q CHP Q CIWMB 0 Complaint Q Educational Visit 0 Other <br /> Business or Facility Name ` Inspected B <br /> ] 1 p Y Inspector <br /> Vri^ L � <br /> Physical Address l Q 1 itj 0.skv� <br /> f, ��U� Inspection Date <br /> ,/�•J�l 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) i (Fill all that apply). <br /> 1 0 Active O Passenger 0 Generator Q Outdoor <br /> O O Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive * Truck <br /> Longitude - O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • Trucking Fleet O Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder C) Other <br /> Part B - Inspection of Waste Tire Dealer, Generator Hauler and End-Use Facility ENFORCEMENT$TATtS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notl6e 0} Vtolatlon {� E�ctifj7t��Dt�; <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 10 PRC§42953-Contracts with Registered Waste Tire Haulers. Cotr1p118fLC6'De�s(Ilga ; y ' <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements 1 pate I I I f f <br /> 0 Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CtW MB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RgUlrppfttlF/�jflTt}r �'�„ <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 1 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 � � § Y q <br /> _+� / ` ✓i'ice,f <br /> Q 1* 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators . � � s �•s '� ";,"i>'f�j <br /> 0 Other: § l � x'T .� <br /> Comments 4 <br /> SaM t~ Non t�rr�y►-f�%2�i <br /> �/� /�a7 u 1x Bj�lcoQ a G �/y�c d- coax 'y . o <br /> �- 7_��1;-� <br /> Inspection Form Included: O 9 4� <br /> Comments Included: - � - - — - - _76«10 <br /> - Business Rep's Signature Phone Number re Phone Number <br /> INSTRUCTIONS ON BACK I dor rt3ctiA Rh P 3 620131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />