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Waste Tire Survey & Inspection Report Inspection Report Number <br /> 11U State of California <br /> CIWMB 181(NewSurvey Form - Page 1 ( 3 . 1 0 2 5 71 7 <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 /> G <br /> Site Suffix: j 3 d -1 7 - { 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �"�� If Referral,choose referral type(Fill one) <br /> Identifier: V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> j ��� �Inspected Byr O Inspector ~ <br /> ysica�AddDl4s <br /> Inspection Date O z l � 6, ' Q <br /> Time In Time Out <br /> Business Rep Title ' O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business 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 /> 2� <br /> f ° 0 Active * Passenger 0 Generator • Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor � <br /> o iQ Inactive I 0 Truck <br /> Longitude - l Q Planned Q OTR I Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber t' <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 f.91 ffQRCNMENT STATUS <br /> w' A HAULING ANDWA NIFOST R1 QUIR9MENTS V <br /> Q + Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires Q Nctlae Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C.gfnFillnRQ IJaarAlne <br /> Q I Q PRC§42956-Registration/Decal in Vehicle <br /> O O 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date"l__ t__.f l m f <br /> (] I Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB J k <br /> O O 14 CCR§ 1B459.2.1 -Submittal of Manifest Forms and Tire Trip togs within 90 days k (R¢qu)redfgrNOVor00T) i <br /> Q <br /> �O14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yearsQ4 CCR§18480.2-Manifest System Requirements for Registered Waste Tire Haulers QQ,", f r p.mms r Enforo ent <br /> i'J l Q 1�R18411 anifest System Requirements for Waste Tire End Use FacilitiesQanifest System Requirements for Tire Dealers or Waste Tire Generators H 1 t+1o_Ylo�, } <br /> Q{Itsp iii► �. <br /> Other: § ; — <br /> Q-��—�—L --— —�I— � — —�--- — — — — ---/ - <br /> Comments /ZOt�l -Aitt, St'6 V\ ey GCND�/ ((/l�f ei' diler�VI,4^� <br /> �}rco-og 64W l Mrn%- `� CC 1��bob S moi► �5 <br /> wrR- rs � 1�at.��e,� b cot <br /> u 1 SN-cra- l`41LLae i _t'S 61_-5_6Uetnk_t <br /> Inspection Form Included: O $ /g <br /> Comments Included; Q #%6 <br /> 60 <br /> Business Rep's Signature hpneIVber I gPhone NumbeB <br /> 62081 <br /> INSTRUCTIONS ON BACK CIDPI�R#t. t� � N C 'X +MI PLL E 1 ' 2 2 3� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />