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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Calitwnia <br /> CIWMB 18asteManage Survey Form - Page 1 1 4 . 1 0 1 3 6 7 2 <br /> c'to Integrated Waste Management Board <br /> Part A-=; _ BLUE OR BLACK INK PEN <br /> Business:Profile _ Inspection Details <br /> TPID- / O - inspectlon Type (Fill one) — — <br /> Site Suffix: D 0 Routine 0 Re-inspection 0 Referral 0 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 Address <br /> Inspection Date <br /> J (a� <br /> Business Rep Title Time In AllTime Out t� � �AM <br /> PM <br /> 0 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 <br /> � 9 � 0 Outdoor <br /> d 0 Al <br /> O 0 Closed GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) — <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT a)Afi)8`" <br /> CJ Notice Of Violation r � <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires Extension' <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Contphance Deadline.,_:.,` <br /> 0 0 PRC§42956-Registration/Decal in Vehicle / `7 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date l <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB . <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days wred fn;NOV of cDC7) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> � s. at <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> .> idAWYa `.vf-d <br /> Q 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 /> 0 0ttr Yirtaltta <br /> Other. § � <br /> Comments �,�;�/ Lt/� p7 r %N > 1'�-y' � T�c•F-,•L <br /> y � �r�su► l`�l` �- �'«.c���� _ .arc ��. q <br /> L!/ l aore-W )4?%ed ar-e *L& dS IAC zee! q � <br /> ,Inspection Form Included:0 <br /> Comments Included:l� U '�� •$� `/` dG/� <= /IZr '✓t✓ lap=�JG3 <br /> 4Bu.. s_Rep's Signature Phone Number Inspector's.Signature Phone Number <br /> INSTRUCTIONS ON BACK l l �''"� ��'f � 'i �f I' '�I� � EXAMp ILE12362081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0624994.0176 <br />