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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ilL State of California <br /> CIWMB 18eoaSurvey Form - Page 1 1 4 - 1 x 1 3 6 8 0 <br /> California Integrated Waste Management <br /> Board ment <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detaits <br /> TPID- Inspection Type (Fill one) <br /> � <br /> Site Suffix: Z l Y 7 © J .Routine 0 Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: 4�Cv'st` �/OQ� G[.hey Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name is - <br /> Inspected By Inspector <br /> za4 <br /> Physical Address 3 9 I o / Si,/36t7�i1/i L,v� <br /> I—ezze-re <br /> Inspection Date D $ / / g / O <br /> L / Time In Time Out a <br /> Business Rep Title AM I <br /> , 0 A <br /> J� 7 O PM O <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE (Fid one only) (Fill all that apply) (Fill all that apply) (Fill all thatapply) <br /> ( ) ' r Active Passenger Generator <br /> � 9 • Q Outdoor <br /> 0 Q Closed O Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude — Q Planned 0 OTR o End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> — I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility EfdFORCEMENT`SfiATU8 <br /> A HAULING AffiMA�tIFES7 RECYU112�1it1I7S` <br /> - - -- <br /> 0 Notice Of Violation Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance.Die ine <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements -Date <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 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 <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities a <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § n <br /> Comments P.�s/ �Cs�i'fy /}'�/� •� ��/�//f//y—t��. �a�G�1 �7 /a�G G�'4'.f <br /> �ref����a�� c�-�-riire _ 5� /'u�.��/�ye �rr'cr� �/'•y �il�L �/,�,u�/v <br /> Ile <br /> Inspection Form Included:0 <br /> Comments Included:Q— <br /> siness Rep's Signature Phone_Number Inspectors Signature Phone Number V <br /> ■ INSTRUCTIONS BACK 111 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0626304.0276 <br />