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® Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ur- <br /> °� <br /> star.of181 fo°� Survey Form Page 1 1 1 5 01 3 6 $ 1 <br /> CMlMB 781(Nrw e*/04) <br /> callfornla Integrated Wast*Manage fft Board <br /> Part A-Survey__ _ BLUE O ,K INKTEN <br /> Business Profile r _ i Inspection Details_ <br /> TPID- { I l I O I Inspection Type (Fill one) LU U J Wi Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation . <br /> Local ( N Referral,choose referral type(Fill one) <br /> Identifier. I{ y�Q, �'� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B ~ <br /> D / P y Inspector <br /> Physical Address (J / <br /> ri -209 <br /> Street <br /> Inspection Date <br /> City [� State LIP Code Time In Tlme Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM i ( PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply)I (Fill all that apply) <br /> _ 3 ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> � O � Q Closed Q Altered <br /> GpS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> I� Longitude — Q Planned OTR End-use Container <br /> � <br /> Business Type (Fill all that apply) <br /> 10 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 / p� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 9 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility` _ENFO_RCEM_ENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS ` Q Notice Of Violation Q Extension <br /> IQ Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q I PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> IQ Q PRC§42956-RegistratiorVDecal in Vehicle <br /> Q ! 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Date M/111 / 1E <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Lags within 90 days (Required for NOV or EXT) <br /> Q 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 Referred f CIWMB Enforcement <br /> Q Q 114 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other § <br /> Comments <br /> - <br /> le,q o fC COr�ursr /8�/SpTpAPpau��' fP — <br /> Inspection Form Included/:`0 <br /> Comments Included: -- — ��3L8e4Z7 <br /> _ slness Re •s Signature Phone Numb_er Inspector's Signature — — phone Number J <br /> INSTRUCTIONS ON BACK (Correct:* Incorrect:?VVgjjEIXIAjMjP1L1E1 1112131 62091 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ■ <br />