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Inspection Report Number <br /> Waste Tire Su4by & Inspection Report <br /> State of Survey Form - Page 1 13 - 1 4 1 4 3 G <br /> CIWMBB181(New 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: , © Q - / • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ' v l0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I� / Inspected By Inspector <br /> re- <br /> Physical Ad ess � � f j �r� ,q <br /> Inspection Date <br /> �7; I-y Time In Time Out T <br /> Business Rep Title O AM O AM <br /> ' 0P 0P <br /> r- <br /> C Operational Status Tire Type Business Role Storage Type i <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I&Active I* Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 1 Q Hauler I Q Indoor <br /> O <br /> 0 Inactive Q Truck <br /> Longitude - 0 Planned Q OTR 0 End-Use Q Container <br /> I Business Type (Fill all that apply) <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> ... <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> i V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> CCR <br /> 14 18459.1 a) b)(c)-Tire Program ID Number from CIWMB I—J—J 0. [1. <br /> O O § <br /> Q 0 ! 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R8qutred fotfYOV:or, <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years T _. <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0, Refei'ired!CIW[1118 F(fO�Q�mtF ' <br /> 0 0 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators j <br /> IFI COF11p1IpfFce f+I+D VIFf•�.��- <br /> 0 Other: § --} -- �f <br /> Comments l 17r ' � GTS y G �%^rte H ) F 1 ck, L-4 l <br /> },,Jh&4� *res -4W I C q_ w w,64. • <br /> T ICA Q t�4�I''t��s-� cJf�f P-� (�1,.s r' �a 7't <br /> . I1 <br /> j-,-o,,4,54-5; -b Ar-,Etf' <br /> ,Inspection Form Included: Q <br /> Comments Included: Q' f <br /> Burin s R 's Signature Phone Numbgr Ins c is Signet Phone Number ; <br /> _.. ._.. 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect:_ E: X A M p L 12 3 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />