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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMBt81ea4agSurvey Form - Page 1 I 5 - 1 0 1 4 7 7 9 <br /> California Integrated WaststM <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - <br /> I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 2 5 ) 4- fJ ?� Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Gov- CK� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> 6y ,,��Iddress� <br /> CA <br /> Inspection Date 0 <br /> C <br /> / <br /> r , Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> QPM QPM <br /> I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �t O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f o Is Active Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler I� Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) L <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT$TA'CU$ <br /> V I HAULING AND MANIFEST REQUIREMENTS j <br /> 0 Notice Of Vlglallf n <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> b�tRt3}taXpl� <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Cantplllk_ndf Deadllths <br /> 0 0 PRC§42956-Registration/Decal in Vehicle "y <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dat$m �% <br /> 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 (IBqu!�f�(�ctrIf3V�� j : <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years f/ <br /> 0 0 14 CCR§18460-2-Manifest System Requirements for Registered Waste Tire Haulers I � l l! ►(I � s � i <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 /> 0 0 Other: <br /> § <br /> Comments <br /> x e- L,)'64r✓ L <br /> LJeA /- �r7�j ��rjv�c� Aoe,, ) �6i•-"1a <br /> �i �`?t� CX+? =e< �� ��`�'Ttirr.c'Ttr� <br /> t�,•5 i'7�, ova r� ! le w eo," . <br /> Inspection Form Included: 0 1 <br /> Comments Included: Q - - — - — - 1�1c <br /> Business p's gnature Phone Number In pector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Cofr� � 1nC�7Ci 62081 <br /> ` { , XAPLE 123 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />