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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> SWMB California Survey Form - Page 1 1 2 1 0 1 3 1 3 4 <br /> c04) <br /> 8NM8 181(New 041 <br /> California Integrated Waste Managemont Board <br /> Part A-Survey _BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ? p Inspection Type (Fill one) <br /> > <br /> Site Suffix: 4 6 3 7 - 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: C�G_-u-h C�p[e. — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business Facility Name 0 inspected By Inspector� <br /> Jn d/OQ��rr <br /> Physical Address 3 9 - / Scc�/J�Q /Y/ 7t/. <br /> ,23S_ �c-���s � <br /> Inspection Date � ( / � $' / 06 <br /> JAS t"n C r Time In Time Out <br /> Business Rep Title O 7 0 AM .� — Q AM <br /> L 0 PM 13 G <br /> / 'Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' *Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder !Other Gc«< y <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility T! It ENT`STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS -- <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> r,Q Notice Of Violation Extert$fon <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ComRtiance Deadline- <br /> 0 Q PRC§42956-Registration/Decal in Vehicle `. <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> QQ 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB 111 III III III III <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> t" (Required for NC7.V or FX7) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 3e <br /> Q ' Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred 1 C8WM6 Enforcement <br /> Q 014 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities " <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsS <br /> lr cpmpt+ance No ViolatlOfl <br /> Q . Q Other: § <br /> 1 J / <br /> Comments �' °�- 4 <br /> axee <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> BTslness Rep's Signature Phone Number Inspector's Signature _Phone Number <br /> INSTRUCTIONS ON BACK jEjXjAjMjPjL 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ ' <br /> G1r4 1=14.X171 <br />