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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CtWMB tet stew gSurvey Form - Page 1 1 2 . 1 0 1 4 7 6 6 <br /> California Integrated Waste 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: Zq Z --7 CO 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � ttQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> IInspected By Inspector <br /> Physical AddresC 73 q — ' / c <br /> 153-3c�- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Q PM O PM <br /> I i Uiy�ytnCtr thi�I$G y� Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE) , f (Fill one only) (Fill all that apply)' (Fi11 all that apply) 1 (Fill all that apply)4 <br /> f l 0 0 4P Active Q Passenger Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler . Q indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned Q OTR O 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 O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORC M,ENT 6TATIIS._ <br /> V I A i HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Ii,Extansl9n <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance.Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 ! O 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 Logs within 90 days (Required for N0V w9XT). <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred 1 CiWme ERftarpam�nt; <br /> 01 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> ® O 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q iq Complfelnae Nq Y13SftYgtht <br /> Other: § �._:..:. <br /> CommentsrY�41 — <br /> N a I �its c,i,-� v� 1 l e- �;'�• fir'► - �-- i (,X04L <br /> �►.l�.r <br /> 4_0 <br /> Inspection Form Included: Qru <br /> Comments Included: I rj <br /> Business Rep's Signature Phone Numberspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct;* Incorrect:X ( (V; EX_A NII PJ .1 3J 62081 <br /> White Copy.CIWMB Yellow Copy'Operator Pink Copy:LEA <br />