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Yi <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWM f 81(New <br /> Survey Form Page 1 1 4 0 2 56 1 0 <br /> CIWMB 181(New 04104) . + <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f Q -5 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: +� �'- i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> business or Facility Name <br /> iInspected By Inspector <br /> Physical ddress <br /> Inspection Date � [L I � / I <br /> Time 1n T Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> {..�1 t�ih'bl'� �Jlw'r��f D "�✓" Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) + (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> f I ®�ctive ® Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O I Q Inactive I Q Truck f <br /> Longitude - O End-Use Q Container <br /> Q Planned Q OTR <br /> 1 I <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 + !~NFpFGSIIgSNT STATU.3 ...... <br /> 1A; HAULINQ ANtQtiM4NIFEST REQUIREMEMT$ Q Notice of Violation O Extension { <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q I O I PRC§42956-Registration/Decal in Vehicle j <br /> 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> O + O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from C)WM6 <br /> • Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days I (Rsgvked for NOV orE" <br /> O Q j 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O I O 114 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers f Q RR�@FEed 1 CIVWMB Enforcement 1 <br /> Q O 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 /> !ft �iRlit flen�4 �:NQ.Vlollltivns <br /> O O I Other: § ��y� <br /> Comments ^��^I '( 13+�51� g5 C3 .51 5- "v1 <br /> - 2z — S" , 1-•1 1a--- G � [a 5 d��d l 1-w 10,.- 1 s <br /> _T_— - 4 - - <br /> Inspectlon FormIncluded: Qty <br /> Comments Included: Q b <br /> Business Rep Signa re Phone Number In t s Signa ure Phone Number <br /> 62081 <br /> • INSTRUCTIONS ON BACK I�'l?13'a 11l+tfQ>E`�� lV, 7( r0.`INt P i 1, ) 1 2 3 <br /> r. _ <br /> �.. _ _. _. <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA Entered <br /> KB <br />