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I <br /> Waste Tire Survey & inspection Report inspection Report Number <br /> State of California Survey Form - Page 1 1 6 - 1 0 2 5 12 8 <br /> CrWM8 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L .Routine Q Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical�V <br /> Inspection Date / <br /> / Time In Time Out <br /> Business Re{{f Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / '02 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> t ' ® Active ® Passenger a Generator j 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility '._ENFORCEMENT- <br /> STATUS_ <br /> .. . - <br /> ;.' A > HAULING AND MANIFEST REQUIREMEN S Q Notice of violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registratior and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers, (f Compilarlae Doadilne <br /> O O i PRC§42956-Registration/Decal in Vehicle m <br /> QO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> O O 14 CCR§18459.1 (a)(o)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O HO 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q IRelfarrsd l CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ^ I 111 Cofn llancs . N6Vlglations <br /> O i 0 Other: § _ <br /> Comments �9� �isf /f�J>✓. /ki <br /> /�'r�Iv1i+•► o� .�- �'"�ccg o// C�rxd'.a'�-v�L-- a'� �`i•-►-r c o� r ` <br /> --��/,(PI'S r _ ••'�r f� !// ,,rZ.t,,�/„��� �_c����' Gl t✓�"!t3 - - - ' <br /> Inspection Form Included: Q Z 7�f <br /> Comments Included: - �/ <br /> Business Rep's Slgnatur Phone Number )ns ure PI 7ef 11�r <br /> INSTRUCTIONS ON BACK CQCt'8tit`*.` Cn ar#`a>aIt _ L E`J1 �3 s2 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA_ ■ <br />