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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ofCalifornia Survey Form - Page 1 1 6 - 1 0 1 4 8 5 4 <br /> CIWMB 181(New 04104) <br /> Callfornta Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> (Business Profile - Inspection Details <br /> 1 <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: 0 t� ( (a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phys cal dress <br /> '39 <br /> 6.7(K Gn-az-- 1.�t ii <br /> �f Inspection Date <br /> Time In Time Out 7 <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 4 0 Active a Passenger 0 Generator Is Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude - 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer dj 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 <br /> V <br /> _k HAI LIN©AND.MA llFEST RSQU(RSMSN'�I� (Q'Notice Of 'Vlolatlon 4$ ExIonslon <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. i �ompltttnGsa Uoldllns <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pAte I I t l / J <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CfWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (ROS 4'Bd.forwovor E)M <br /> O O <br /> 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 t�tClOnt <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 ! I9 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> �}I3k Ti �f.+t.--Np 4MIi�1> ns <br /> 0 1 0 Other: <br /> Comments 3 _h <br /> r ((nY�fr S �0� Q'V�%IIrCG.�IPi �Y1���r+�� • Fl�'Aai J�jii 4 l Co <br /> � �i�i►�sp�i�'---r <br /> Inspection Form Included: 0 A r_ <br /> Comments Included:O 4 �-D 4 Y 7 <br /> MWgnature Pho{te Number I t 7Sign Phone Number <br /> 'x �'',/ i � '" '� 62081 <br /> INSTRUCTIONS ON BACK1 ? A'�Vi Ev <br /> � � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />