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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB1B1(New 04104) Survey Form - Page 1 f 1 - 1 0 2 5 8 71 <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; 7. 7 © +Q Routine ® Re-inspection Q Referral Q Observation <br /> Local ,If Referral,choose referral type(Fill one) <br /> Identifier: G,r~. ` � �r�-��� �y � � I Q CHP Q CIWMB, Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 1 <br /> Inspection Date I) 3 / �, / ,' <br /> Time In J Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> 1 ee <br /> Y <br /> $` 1Lr rr— l rs�(s v1 �w Operational Status) Tire Type l Business Role Storage Type <br /> Tire Count(Whole/PTE) I(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r • Active o Passenger I ®Generator Q Outdoor <br /> Latitude O 10 Closed Q Altered <br /> GPS I � Q Hauler ® 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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tiro Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder &Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENT STATUS <br /> V t A I HAULING AND MANIFEST REQUIREMENTS � <br /> O Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Q FIttenslon <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 m <br /> Q O 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days C fRequlmd for NOV or E)M <br /> 01 O . 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O {14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ( Q Referred/CIWMB -Enforcement <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> No Viol <br /> �O <br /> 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I 1,111 rnpl1& ViolationsOIO § y q I <br /> Q L Q Other § <br /> Comments I <br /> i <br /> i <br /> �Inspection Form Included; Q fr44 /� <br /> Comments Included: <br /> Ql K`J <br /> Business Rep's Signature Phone Number I p r fgnatur Phone Number <br /> INSTRUCTIONS ON BACK I Correa: `IltcoKrect ( V 4�Ej <br /> �l h�IR t`�. , s2oa} <br /> Mae Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />