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_= = Waste Tire Sur ,y & Inspection Report Inspection Report Number <br /> Staten 181(Now <br /> Survey Form Page 1 1 1 1 U 2 5 8 3 9 <br /> CIWMe 1B1(New 04)04) 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: g 0 ID ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> LLL 7 <br /> Physical A dres 7 - , b <br /> Inspection Date b 3 / t7 Vu ` <br /> L-- —" Time In Time Out <br /> Business Rep (f Title1 O AM O AM <br /> sit, � O PM O PM <br /> Operational Status The Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply)' <br /> f f 0 0 Active (a Passenger ' ®Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> C Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> FQRCf»MEN7.$TATU8.._ <br /> V` A► _I HAO.6 �AANI�Efi'RQUIIIIANT$: <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q_Notica Qf Violation Q Extension i <br /> i <br /> Q Q !PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance pesdllns <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I I <br /> Rath m m m <br /> Q Q ; 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requlred for NOVorEX7) <br /> Q 1 Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 01 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers E�l1�I'1�a /plVltMB 11fQ1CamMt <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators _ <br /> Q <br /> 0 <br /> Other: § <br /> Comments-_— ��„>«C� `p�(UIZG�✓� � �/l7U'S� ' ( �lf"L-5 � <br /> V <br /> 61,1 l wwV`t l ti� <br /> Inspection Form Included: Q _ ! <br /> Comments Included: Q <br /> B !nos s R gnature Phone Number Ins ector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK _ !# � s [ 1� Ip �:11t <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />