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Waste Tire & Inspection Report' Inspection Report Number <br /> ur Survey p <br /> CIWM f 81(Nfnld Survey Form - Page 1 1 2 - 41 4 7 7 <br /> CIWMB 181(New 04104) <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: f 4 f <br /> j �^i' . Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f. If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Comptaint 0 Educational Visit 0 Other f <br /> Business or Facility Name 'tY� I Inspected By Inspector <br /> W In C.t�r.r-a <br /> Physical A cess 6 �? Gj - C-> <br /> � <br /> CA '?5'3;'7 7 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I)AM 0 AM <br /> O PM O PM <br /> iOperational Status Tire Type Business Role f Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 STATUS I <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extannl.On <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 Date <br /> a / I <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 1 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required(or N0tibr£C17 ' <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Rt>f9rtad 1 CIYVNI@gft{TfffM <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities % <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In <br /> Other- �§ (+'j' <br /> _,1 <br /> Comments �„i c'Lh ctc` r eKO AQott 1c�61.a_ s �,.,� t M^e.T`^r�.. 4� Uk,— Gt'C� <br /> 05 4�54-5' q'i <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct e Incorrect: (� E X A M P I- =1f s2os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />