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i , Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California ■ <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 1 3 - 1025626 <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: 1 3 t' ®-Routine Q Re-inspection O Referral Q Observation <br /> Local �.�+ If Referral,choose referral type(Fill one) <br /> Identifier: r 11— GZkA C— H[) Q CHP 0 CIWMB O Complaint O Educational Visit O Other <br /> Buslnesr Facility Name Inspected By Inspector <br /> Physical Addless <br /> &6LOo'e, <br /> Inspection Date 5 <br /> Time In I Time Out <br /> Business Rep Title 0 AM O AM <br /> �r`� �►-dlhQr t"aw�5 v"I4r+q 0 PM - 0 PM <br /> Operational Status' Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (or 1I one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> *Active S Passenger 0 Generator O Outdoor <br /> 0 Q Closed j O Altered <br /> GPS Latitude O Hauler Indoor <br /> O O Inactive Q Truck <br /> Longitude O Planned Q OTR O End-Use O Container <br /> Buslness Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body •Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O Other + <br /> I <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility i ENFO&C .MENT-ST�►'tIJ os� <br /> V HA6LINt3 AN©MANIFEST REQUIREMENTS <br /> Q <br /> O O Notice: f Violation Q..Ex�A1Si�P �y: <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> d.. <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. CatnpllapGe Deatdllne �,'y~5 <br /> }• <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (f�9i)tall&it ftfl IV3y %i''�j; <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> _: <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 1t$ttaellQtW �� <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> �. ice•, <br /> O O 114 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators , <br /> O O Other: § ! ^>a ` <br /> Comments r p v4,,v d4,.c /i Ie,— 57e l// -bkv' wl1�j - Rfc0V 1i✓G�` ` <br /> w(�� � Uri�jr"K� c,c.,ao.�. `�-� W�'�G-• �(/�„ 1�p �S'"�c^ <br /> Inspection Form Included: Q <br /> Comments Included: O -Number-- <br /> fgnature Phone Number n c is Signature Phone umber <br /> _ ` t 62081 <br /> INSTR%jfW b&ON B 60to1-_ Incorrect.. � `r.( /1, PJ <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />