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■ i'� , Waste Tire Survey & Inspection Report Inspection Report Number , <br /> $IotaB t61lNew I Survey Form - Page 1 1 - 0 2 5 x 7 0 <br /> C1WM181 1Naw 04{04 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPiD- 7 ( _ D Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local if Referral,choose referral type(Fill one) Al <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Iy inspected By Inspector <br /> Zai1,. A-.,,Y �, _ o <br /> Physical iddress <br /> 1 I Gd, L OL$to l -X4 S <br /> ��3 I Inspection Date U 6 / � y / (0-5CAO 1 Time In Time Out l <br /> j Business Rep Title I O AM O AM <br /> O PM O PM <br /> Operational Status Iy 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 r 0 Active Q Passenger 0 Generator .49 Outdoor <br /> � O <br /> Q Closed Q Altered <br /> GPS Latitude 00 t* Q Hauler Q Indoor <br /> Q Inactive 1®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) ! <br /> s= <br /> Q New Tire Dealer Q Auto Repair TriaAcking Fleet 1 .Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q CA"r Dealer Q Col tiln Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shre� Q Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ` NFORCEM_- .T_STATUS <br /> V A HAULIN0 4ND MANIFEST REQUIREMENTS �Q Notice Of V oletion Q 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. l Compliance CH adline <br /> Q Q PRC§42956-Registration(Decal in Vehicie <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> Q I Q 114 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Raqu' d for NOV or EX7) <br /> Q Q 114 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I <br /> O 1 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q R0farr9d/ IINMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O ; Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators id 11n, 011a,Ce - No VtDlAtlona <br /> 0 I Other: § <br /> Comments <br /> U I' <br /> iInspection Form lncludod: <br /> Comments Included: Q <br /> 1 Business Rep's Signature Phone Number s s S' attire Phone Number <br /> Number; <br /> . ., _. 62081 <br /> INSTRUCTIONS ON BACK 4'orreot: (rtaot)`e�t� < v, I �' L ! 1 =2� <br /> I _.. . - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />