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„ Waste Tire Survey & Inspection Report Inspection Report Number <br /> N ■ <br /> State of Survey Form - Page 1 0 $ 0 9 <br /> CIWMB CaliforniaCa (New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE_OR R BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: outine 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 Inspected By Inspector <br /> k71A W u_ti <br /> Physical Address — li <br /> �M Inspection Date ` / 1 l / p 7 <br /> v U^� �33� Time In Time Out <br /> Business Rep Ti`tle. O AM 0 AM <br /> ISN t/u O PM Q PM <br /> y 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 /> f P ; ger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> i <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 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 <br /> ENFORCEMENT STATUS-._-. ....__: <br /> VA HAULING AND MANIFEST REQUIREMENTS Notice Of Violation <br /> 0 0 .PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0: Xt8ti810d <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. 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 /> 0 0 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (hequlred forN04lor�{i) <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 Rsfelred I CIWMB Erifolhparbelt <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 ;14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 Itf Cartt�l}atio/t��Atq���G�y, <br /> 0 0 Other: § <br /> Comments <br /> S <br /> Inspection Form Included: 0 <br /> Comments Included: - ?er <br /> 41n <br /> BusinessRep's Signature Phone Numctor's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:O Incorrect: ( j �%J J ly X R P I L Jt12 3 62D81 <br /> White Copy:CIWMB Yellow Copy,Operator Pink Copy.LEA <br />