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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of <br /> CIwM Survey Form - Page 1 1 7 - 1 0 4 7 8 9 <br /> CIWMB 181(Naw 04104) <br /> California Integrated Waate Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z 7 C7 t Q RoutineRe-ins ection <br /> ® p Q Referral Q Observation <br /> Local If Referral,choose referral type(Fit(one) <br /> Identifier: ' <br /> � �„ ;,,� �j�,,,-�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1r� .ter• /� <br /> GCr J vacjtnt�- iski\ trA..."+D;54h� <br /> Physical Address 3 q - / p ( ���, � �s <br /> �— <br /> .! � <br /> CIATime <br /> Date 0 2 / I C) J <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fil)all that apply) (Fill all that apply) <br /> f ®Active Q Passenger O Generator f' Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude f Q Hauler Q Indoor <br /> O I Q Inactive 0 Truck I <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 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other �S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFO.RGEMENT STATUS. ._._ .._ <br /> 'Vi[+ A' HAUJ INQANCI<MANIFE$T REQUIREMENTS <br /> *Notloo Of 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. I Comp4me Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle 1 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dote b 3 I 1 I O S <br /> Q Q 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 (lRegb1md for NOV of 0? <br /> Q 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 t 1elFr d!OIWMI3 Enforo0rltottt <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> d 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators0 10 ` <br /> � ICI�Irrltpl►�Incta� Na Vlol# ns .: <br /> Other: § <br /> Comments IQ �SR- *, :Isle, ►i'�- (M�.h1—C"4-sy Gr,Sffe s H, n,f 5 <br /> 11 1.� <br /> h 04- <br /> vtJ M�11---?'S 4r- <br /> A ISO uso, afard�d_p_r�S <br /> Inspection Form Included: Q6X <br /> Comments Included: Q - r � <br /> Business Rep's Signature Phone Number Ins o s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK iipl" i , Iii l �;N1 ( A ' P� L Y 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />