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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Ir State of California <br /> CIWM8181{NGw04/04) Survey Form - Page 1 f 1 0 2 5 7 7 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D Inspection Type (Fill one) <br /> Site Suffix: ` !� ( 0 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 ddress <br /> lC14 5 <br /> CA Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> QPM 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q Passenger ®Generator f *Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive � Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 40 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 Hauler Q Agriculture Q Shredder Q Other - r-Ar <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORGEM NTSTATUS <br /> V. A; I HAULIN(Ill MANIFEST REQUIREMENTS Q Notice Of '/IolaUon 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. Compliance rAndtine <br /> Q Q PRC§42956-Registration/Decal in Vehicle j <br /> Q Q14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Date� � <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CiWMB jE __ IT <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Regared for NOV orF_XT) <br /> Q 0 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 (DRafrr ed!ClWMB- 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 /> i -lrt pit ince No Vlolatlons <br /> Other: § <br /> Comments <br /> � %Aessaf/ 1 1� 'Y-aa�r� �vrs CLA, ski )` as �wv <br /> !7 rs 1 ►� p1 aG T t ns GV't_�CCGC 5 awt tY <br /> Inspection Form Included: Q <br /> Comments Included: Q >,— <br /> Bus R 's Signature Phone Number or Phone Number <br /> INSTRU N BACK Carr�t:k; In orreC#, ' 62os1 <br /> KS While Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br />