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i Waste Tire SuRey & Inspection Repori0Inspection Report Number <br /> State of Callfornla Survey Form Page 1 i 0 2 81 0 <br /> CIWMB 181(New 04104) � w <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details j <br /> TPID- d� p Inspection Type (Fill one) <br /> Site Suffix: ` 3 \ Q Routine 0 Re-inspection Q Referral Q Observation <br /> r <br /> Local If Referral,choose referral type(Fill one) <br /> 1 Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> S a�vA T i 4'-C ~' <br /> Physical Address 1 <br /> Inspection Date <br /> Time In Time Out l <br /> Business Rep Title O AM O AM <br /> 4 O PM O PM <br /> Operational Status, Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) <br /> '(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �' <br /> Active Passenger ® Generator (fl 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 0 End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> /—) Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture 0 Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCOMENT 41TATU3___ <br /> Ar. HAU:1Wt3 Ahip AM 401"<REC�UIF�ISfIfN�'8 Q NotlCe Of Violation Q Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. (compliance.Desdllme <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB II II II <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required fbrN0V orE)M <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -- " <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers .Enforcement i <br /> Q Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators s { <br /> Itx �3 pIfAt1 l- YLelatts�ns <br /> 0 0 Other:Comments. �UR$� L �Ti't-' — _ �v wV��- - - - �-L •�.-Vr`1t�t ,[ � �fj`C.� w� <br /> Y! <br /> GVi L('"+L v��•V�^� I k�t fq,�^t-4 l Vii 7 ww� l� S` �br� 1 � �! <br /> Inspection Form Included: Q x l / •-, _v <br /> I clu ed: [ �l� - 2 1c7t 5. S 3 19. <br /> Comments n d 0 Business Rap's Signature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK G''OtI` t3 t �lI'� X C yf� i' L s_L11 Z=] 62681 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />