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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CrWM 181(New <br /> purvey Form - Page 1 { - 0 2 7 $ <br /> CIWMB 181 thew 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey Inspection Details BLUIE OR BLACK INK PEN <br /> Business Profile J <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: 644 Routine Re-inspection t� Q p 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 /> Physical �� �— <br /> Inspection Date <br /> 1 Bey � GA 553-7 D <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> C) PM O PM <br /> 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 /> ' •Active Q Passenger •Generator Is Outdoor <br /> Latitude C Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> C Q Inactive 0 Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 Hauer Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility .ENFORCSNT STATUS <br /> . <br /> ---------------- <br /> u;i A HAUL ING<IND MANIFEST q QU1REMENT$ Q Notice Of iolatlon 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. I Compliance Leacillne <br /> Q Q PRC§42956-Registration/Decalin Vehicle m <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I I l <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requ red for NOV or DCT) <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 Refarrpd.1 IWMB Enforcement <br /> Q Q .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 /> 0_L0_ <br /> Other: § I1hIQIY(hll No Vlolatlons <br /> rice <br /> Comments Q _ 1Ivse, I%'IS7 r_04-l^,�V5 �f'C. 1 �1t �01t �+1Q� W+ r N.-,k-A <br /> t� tom./m�>� v,,�r / <br /> c►nr��o1, wa j vAAj <br /> Inspection Form Included: Q <br /> Comments Included: QF �3 '7 *1B <br /> I Business Rep's Signat a Phone Number <br /> � In c t Phone Number <br /> INSTRUCTIONS ON BACKCorrQa�;OIncc�r+allt ^7� A ,N, p 1 s2os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />