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Waste Tire Su&y & Inspection Report Inspection Report Number <br /> t=fir Stateof California Survey Form - Page 1 2 - 1025658 <br /> CIWMB 181(New 04104) Y <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: 3 Lt tv 7j ej f ® Routine Q Re-inspection Q Referral Q Observation <br /> Localer+� g /' �f.� If Referral,choose referral type(Fill one) <br /> Identifier: �'f�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r << Inspected By Inspector <br /> lJ p <br /> �� <br /> Pei Foe-o4� c <br /> Physical Addre!Ss - <br /> Inspection Date 05- / I � / O IS" <br /> Time In Time Out <br /> Business Rep ,Q J� Title O AM _ O AM <br /> 1 �G'�y 1�i N�S 1 C;v-� �i•�9 �tf-- I O PM QPM <br /> / 9 Operational Status Tire Type Business Role 1 Storage Type <br /> Tire Count(Whole/PTE) S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> p <br /> ® Active Q Passenger 0 Generator 41 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use I, 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 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other ,-��{-�� �i�« <br /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i,t~N111NT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS ' <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Nsltl Of Violation Q Extension <br /> ,Q O PRC§42953-Contracts with Registered Waste Tire Haulers. ComjllaAC+! Dead line <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date. <br /> Q O i 14 CCR§18459.1 (a)(b)(c)-Tire Program tO Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days flR gU.ired for.NOV or EXT} <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> s i <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q R r 1 CIWMO Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities STM <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' <br /> �:t illeltc8 No Violations <br /> O O Other: § r t <br /> Com�menMts :� 7 ` 3 j L /G �`�►t , L Fr -5 <br /> �(-- �i <br /> �" V? d <br /> Y <br /> ��'� wr 11 1i,��.. 1 �fres � �,�ox►'� - X q <br /> �n��l� sem' �,- � +� �F -� o \ <br /> .Inspection Form Inclu : Q �j' , _T t�- <br /> Comments Inclu "g- ' �� <br /> Bu ness R Ig ur ne Number Ins ignature Phone Number <br /> INS RUCTIONS ON B Corr 411:1.0 Indo.ratzX� .� L_7C ',�-F Lf� .f 3� 62081 <br /> White Co :CIWMB Yellow Copy.Operator Pink Copy:LEA <br />