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Waste Tire Su*ey & Inspection Report Inspection Report Number <br /> State of California s <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 1 3 1 0 0 650 2 <br /> California Integrated Waale Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ / inspection Type (Fill one) <br /> Site Suffix: 3 6 ( Q Routine I®Re-inspection Q Referral Q Observation <br /> Local ' _�' If Referral,choose referral type(Fill one) <br /> Identifier: , <br /> D Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> Physicai�— <br /> l Address f a ( S <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> �>C/fit t�� 'u"�'��.r1�►� Q L-4—e-r— <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (WhdlelPTE) �-d (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> f r Y ! ®Active ® Passenger Q 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 O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q Now Tire Dealer o Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantlor 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCER NT STATUS <br /> V A HAULING ANI)MANIFEST REQUIREMENTS ®Notice Of ✓loiatlon (a 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. Compliance lteadilne <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date IF )17 <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB N <br /> Q j Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Regtired for NOV orEXT) <br /> Q 1 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!CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> .Q In il#tMplllince - No violations <br /> Q Q Other: § --------------- <br /> Comments <br /> ----- ---Comments f- IGv�f�TS h'l7`�' �i �dtlll�'j bL�— ^�7r' }�L1�IP�L✓�, �),��'1'f"7�� <br /> Inspection Form Inclyded: Q <br /> Comments Inclyded: 0 <br /> sinT�R p's Signature Phone Number Inspect o s Signature Phone Number <br /> I ; r 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect ( tv; I� I �'�1- 1113 <br /> _ .. _ <br /> Entered White Copy'CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KB <br />