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Waste Tire SL ey & Inspection Report Inspection Report Number <br /> St ate of California Survey Form - Page 1 ! 1 - 1025665 <br /> CIWMB 181 Now 04!04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> :Business Profile Inspection Details <br /> TPID- � � � '51 � � � _ � r 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 ( Inspected By Inspector <br /> in <br /> Physical Addressy' � oyy�� �1 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title C) AM 0 AM <br /> ff Q PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill allthat apply) . (Fill all that apply) <br /> B Active Passenger 0 Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> It New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENIRC�MENT.STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS �NCptftta pf Violation 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. COnlplltljnp6 Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pa <br /> 0 p � lbrlo <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB i <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (1%Ired for NOV or EXT) <br /> Q O _.. _.... . _._....- <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 Q F } [)jd I CIWMB Enforcement <br /> i t � <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0, O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ftllenoe j- N <br /> _lpo Violations <br /> Q Q Other: § <br /> Comments 0 L J Jam+' s _�r <br /> �p 1�,•"•�g��- --�"�h�- w.ay.,-�5-?Z•s dv.5t'� -�i�.— <br /> yti�r 5- /v 11,0�1�,Y-!a._ i�_'F1 (LF-ce4z 1 �;I.- <br /> �t�i [.r,r-- j�2�+n►rP_+vc,--"T"5� -tTj,r- t✓��T� -„�'jV-�- ' +/��l"5: <br /> Inspection Form Included: Q' <br /> Comments Included: Q L <br /> Business Res Signature one Number ect is Signa a Phone Number <br /> INSTRUCTIONS ON BACK 'Correct; inaorrsct; (, ) �/i [t~L A^W41 P `I� 1 t ! �3J 62081 <br /> I. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />