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Waste Tire Su- :y & Inspection Report Inspection Report Number <br /> Stala B 181 fNow Survey Form - Page 1 13 . 1 0 2 5 91 <br /> CIWMB 1B1 Now 04104( <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile J Inspection Details <br /> TPID- I _ Inspection Type (Fill one) <br /> Site Suffix: f 0 Routine O Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> &4t, 0 <br /> Identifier: 0 CHP 0 CIWMB O Complaint 0 Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> „ Inspection Date S J /„ / L/ <br /> Six- <br /> Time C� 1 S lfI <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> � ,(��. QPM QPM <br /> ems-5 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t I <br /> 0 Active 0 Passenger ®Generator (a Outdoor <br /> O ® Closed 0 Altered �J/A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> Q <br /> 0 Inactive ® Truck <br /> Longitude — 0 Planned OTR 0 End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair 0 Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture 0 Shredder Other piiclwfet <br /> Part B- Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility ENFORi MN7 STAT <br /> V A HAULING AND MANIFEST REQUIREMENTS ! - <br /> 00 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Nath ►Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> _ ',Daadllne <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Data <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 F�44f1l1 cf fol"NOV or EXn <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 ii"''/CIWMB Enforcement I <br /> O O 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 0 ,Other: )*;'e 7 No Violations <br /> Comments ylr q G'6 1+C, a t S 114e TJZY1'L/UO r-tZ,' <br /> U 1 <br /> St's Ar �C� Lt p 1 Oc/Aetif bq,-hC'P) Cu1d s-hy•ct-G� 'E_ N o �lr y' S <br /> Inspection Form Included: 0: <br /> Comments Included: 0 �� � <br /> Number I ector's i nature Phone Number <br /> ne ep's Si nature Phone Numb J <br /> INSTRUCTIONS ON BAC Correctr,�- Ind'6rroo ('XZ, 62081 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />