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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIW of B181l Nrnla Survey Form - Page 1 1 4 . 1 0 1 4 7 7 <br /> CIWMB 187(New ) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACKINK PEN <br /> BusinBusiness Profile 1 Inspection Details - <br /> ess <br /> - Inspection Type (Fill one) <br /> Site Suffix: *Routine O Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP 0 CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> jl <br /> 2, n IV n•�, j3/v cQ <br /> �y Inspection Date <br /> ` 7" Time In 6 c/ Time Out `{- <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM O PM <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 /> f O Active O Passenger 0 Generator O Outdoor <br /> 0 O Closed O Altered <br /> Gp.S Latitude 0 Hauler 0 Indoor <br /> O <br /> Inactive Q Truck <br /> Longitude _ O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> S New Tire Dealer O Auto Repair Q-trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station O Hauler 0 Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT.STATUS <br /> V<j A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Vlol&Boni <br /> '. <br /> O ; Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire,Program ID Number from ClWM8 <br /> Required tpr No <br /> ( <br /> 10 O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days 1 <br /> I <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I <br /> I // <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers R j I&�R . <br /> C7 O 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities .� /i <br /> p ' .r i pit! <br /> 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators % <br /> , r <br /> O OSoft/PEN, <br /> i,�� <br /> Other: § <br /> Comments /� � [ r a <br /> / '\i�.✓ L�`1�j v.�SsvS �"(�" -'�1 i� A �i-Gsg � �I�.,1�- / !�`F�s <br /> AJO <br /> 'Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number I s at a Phone Number <br /> INSTRUCTIONS ON BACK Cortef = Incorrt A Nt p ] 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA <br />