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= Waste Tire Survey& Inspection Report. Inspection apo Number ■ <br />� stalest 181lNSurvey. Form Page 1 FTI-; 1 Q 1 Q$ 5 5 <br />CIWMB California thew 0004) <br />Waste Management Board <br />aallfomla Integrated <br />Part A -Survey BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -/ <br />Site Suffix:1-3 <br />p <br />/ <br />- <br />I <br />Inspection Type (Fill.one) <br />/ <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill.one) <br />Local_ <br />� <br />Identifier: <br />Qom. V�S=r__ it _��j0 <br />CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name V <br />/za� �S' �-�•�,O A <br />Inspected By Inspector <br />uz - 7[oz , <br />Physical Address <br />Address <br />d <br />( 2.21 7 <br />Street V <br />Inspection Date jS <br />Time In Time Out <br />OAM O AM <br />FT m <br />City State ZIP Code <br />Business Rep Title <br />/ <br />0 PM O PM <br />Tire Count <br />I a <br />! <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Bus iness Rote <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />(Whole/PTE) <br />0 Active <br />0 Closed <br />#Passenger <br />0 Altered <br />®Generator <br />®Outdoor <br />O <br />GPS Latitude <br />0 Hauler <br />0 Indoor <br />Longitude - FM <br />FFT <br />� <br />O <br />0 Inactive <br />0 Truck <br />0 End -Use <br />i 0 Container <br />• <br />0 planned <br />0 OTR <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader ® Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />IllRCEMENT STATUS <br />V A HAULING AND MANIFESTREQUIREMENTS <br />0 Notice Of Violation 0 Extension <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with. Manifesting Requirements <br />Date <br />0 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />(Required fo lVOV or EXE <br />- . ------ ---. <br />14 CCR § 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 O-- <br />0 0 14 CCR §18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred !CIWMB Enforcement <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />®In Compliance No Violations <br />0 0 Other: § <br />Comments,/ <br />%�Y�^ V� «-O�� "�7 /��•�� C'�4� pQv'�O'l° �p � ysP—/"J• iyl�� <br />�/ ] � <br />;Ze <br />Inspection Form Included: 0 <br />� <br />a <br />Comments Included:0 <br />Business Rep's Signature Phone Number Inspector's Signature Phone Numbe8r <br />i <br />INSTRUCTIONS ON BACK Correet:� Incorrect: E X IL P L �' 1 2 3 62081 <br />■ While Copy. CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />