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Waste Tire St, ey & Inspection Report Inspection Report Number <br /> State of California <br /> CWMB grated 1(Now Manage) Survey Form - Page 1 12 - 1 01 4 7 0 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 77 G� Inspection Type (Fill one) <br /> Site Suffix: # Routine 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 /> Physical Address 3 `� \ <br /> Inspection Date C / p O1 I b <br /> l <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> _ 1 0 P 0 P <br /> 1 Operational Status Tire Type Business Role Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> t Q Active Q Passenger Q Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 : Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Relreader 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 Other �srW( (;,C,� ��Vic., �( <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEM9,NT.13TAfiU� <br /> V. A I HAULINR AND MANIFEST REQUIREMENTS - <br /> 10 i Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Extt?n�lan <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C4mpllance DotdltOp <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I I I IQ <br /> Q O 14 CCR§ 16459.1 (a)(b)(c)-Tire Program ID Number from CIWMB L 1 <br /> 0 <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R$f)Lflr�f� l N U;f7f }0. <br /> 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 0 RsfsF4010Ilf_ ' 10.01*ffoAv Jf , <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> rQ O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> ` 0 f <br /> Comments �"�`.��i��� ��Ml�t `[�•t.�-� l�lt�Y�/t'''�c' Cj�''� `j 7 l Z fl c/4 <br /> i,�S.ZK�• �C�K e VA-k't",-t�`. <br /> t'_ (LQ�t,t,i r UJ`rX.ti►1st s S S�,► 1 la.� vv4a-i Vk e"L 1A <br /> Inspection Form Included: Q G 7 f Q <br /> Comments Included: Q; 0*, "+r '�����c <br /> Bu ess Rep's ign ure Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct; lncoitrecti Zvi C X�A�P_ �- ' 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />