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Waste Tire Survey & Inspection Report Inspection Report Number <br /> $tateof ( Survey Form - Page 1 11 . 1 fl 2 7 3 <br /> clwMe 181tst(NewNew aaroa) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID � � � � S O � _ O ' Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Localc If Referral,choose referral type(Fill one) <br /> Identifier: Jr.� ToA gk4l VA COQ-y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I d eal eAs-e- 0)1� S- bC'KbK T►.c. p <br /> Physical Address I — 1 0 i —3— Lt-CZ <br /> r 3 S. Stac k}on S� <br /> ^�C tD V\ C,4 i' � ` I Inspection Date a I O <br /> J\'. !Ja l!f✓_ Time In Time Outl <br /> Business Rep Title Q AM 0 AM <br /> O PM O PM <br /> �r� ✓'^'1 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 /> f ! Active Q Passenger Generator Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive ® Truck <br /> Longitude — O End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 /> Q Service Station- Q Hauler Q Agriculture O Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENT STATUS. <br /> Vi A HAULING AND MANIFEST_REQUIREMENTS C <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation0Xtdptlifgft <br /> ,. <br /> O O PRC§42953-Contracts with Registered Waste Tire Harders. <br /> Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle ' <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 14 CCR§ 18459.1 (a)(b)(c) -Tire Program ID Number from CIWMB IE / m <br /> O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requhvid for.NOV gr <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers Q RsfAned 10W1Vls Ein Or4atn ft ! <br /> O o <br /> 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities i <br /> O . O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § �^ V <br /> (q � J '��JOn <br /> Comments hitu�t.G�es-I-- vIew� . <br /> + 'ViI50vi Wal ire, Aa4 �' -St2� Cz� <br /> ✓Q,+rtao_ Ores o`PproX A pR,*- �, . NO ViialQl"io�qs <br /> Inspection Form Included: Q <br /> ueComments lncldd: Q NV Q 9�W/ <br /> Signature Phone Number t ector „1/Ln✓ <br /> SI nature Phone Number <br /> ,�� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( i ( lei E X A M P1 I F 1 2 <br /> ■ EntOrea White Co CIWMB Yellow Copy Operator Pink Copy:LEA <br /> White py; <br /> KB <br />