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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB1811stNew Mana Management <br /> Survey Form - Page 1 1 7 - 1025786 <br /> California Integrated Waste Manayement Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> J TPID- i � � � � � � � ..Inspection Type (Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � "���Nlr� � �y �KD 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C Inspected By Inspector <br /> I 1 c� <br /> IID <br /> Physical Address <br /> C-A g52-<D3 Inspection Date 0 S I 2- <br /> Time <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> J �/J 0 P 0 P <br /> �J 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 1 • Active le Passenger •Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive 0 Trunk <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Q Shredder ® Other <br /> WI JJlc� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENI b G MFNT_ TATUS _.- <br /> V { A HAULING AND MANIFESTREQUIREMENTS : �, � <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q 40tllf Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Maulers. cc Ilitttfte Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0Q14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements D4 / LL] / m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q ;(6squired for NOV or E" <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days , <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ{# rtid 1`CIWI118 Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0100 Ili No Violations <br /> 0 Other: <br /> Comments If i V-e' I Gi �yT�i�cf `�.��'Y f f% PI'C4' <br /> Ga3�'fn5s c. s I�s� MS'-- <br /> de-au t --i�6 os 04 3 39, No '( Pt D aii,_ 4-Ai5 <br /> s fir c,,11a ~-fir- cz -7-P I D - ----- - -- <br /> Inspection For Included: Q <br /> kSIg , <br /> Comments Included: Q ONS usin s R 's Phone Numbers ( In;ctdr.( Signa u�rre i Phone Number <br /> INSTRUntefe�NBACK �Correct*: Inco'rref� � ,v �( 11__Jt1 .1_ , 62081 <br /> ■ KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />