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Waste Tire Survey & Inspection Report Inspectiof; Report Number <br /> State of survey Form - Page 1 - Q 4 fi 4 fl <br /> CIWMB181181(Now 04!84) <br /> catifornla 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: 1 �j 3 6 r 1 �4rRoutjne 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 /> ��y� �fb ` �1 1 <br /> Physical A�r�e�s� S � IL L v <br /> Inspection DateCA T593 04 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WhalelPTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f 1 � � <br /> •Active Q Passenger 0 Generator 0 Outdoor <br /> C Q Closed Q Altered { 4 <br /> GPS Latitude Q Hauler I Q Indoor <br /> O Q Inactive �Truck <br /> Longitude – I Q Planned Q OTR O End-Use O Container <br /> Business Type (Fill all that apply) j <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder Ce Other <br /> i <br /> Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Part B - Inspe - - -.._....---......' <br /> Vj 'A HALJI INOi 140 M/ft�HEST 5OUIREMENTS <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Qi iolatfon Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0Onlp)IapC6 p. dNne <br /> Q Q .PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ELI / <br /> IE / m <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 9D days { (Rawl d.for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q �efgrlretll 1WMIR Enforcement j <br /> O . O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 � O 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Nfl'Vlol11 on" <br /> O Q Other: § — <br /> Comments <br /> 4 Q i <br /> l,A J;eg� r c two VedC <br /> ,inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signathone Numbe ns o' i Phone Number <br /> INSTRUCTIONS ON BACK f�'r �Rtt9+ �V� {Ir X�+� M DL r t 2 ' 62oe1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />