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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClWM f 81jNrnia Survey Form - Page 1 12 - 0 2 5 8 <br /> CIWMB 1t)1{New 04104) <br /> California Integrated Waste Management Board <br /> 15 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> I8uslnese Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: ('j t/ �o t 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By inspector <br /> PhysiEa[ Address <br /> 7.y�� L�u t 5,.t,• {�v�.� <br /> Inspection Date (� P <br /> Time In Time Out <br /> Business Rep ` hTittlle. O AM O AM <br /> Dv� ��ol.�"(- / (J t�►t� I� I O PArI O PM <br /> "perational Status Tire Type Business Role i Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)i <br /> ° ® Active 0 Passenger It Generator fil Outdoor <br /> 0 Closed I 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 inactive 0 Truck <br /> Longitude - 10 Planned 0 OTR i 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service station 0 Hauler 0 Agriculture 0 Shredder i® Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENF'ARC4 -STATUS..__ <br /> . -. . <br /> {y q HAULING AND MANIFEST REQUIREMENTS <br /> • I0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O NQtICe of Violation 0 Extension <br /> 0 I 0 PRC§42953 Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 I 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements opts I <br /> 0 0 f 14 CCR§18459.1 (a)(b)(e)-Tire Program ID Number from CIWMB m m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) i <br /> 0 0114 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years f' <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Re14rrsd 1 CIWMB Onfomement <br /> • <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *d - <br /> ( txthpl(and :. 1111tl <br /> Other: § 7p <br /> Comments3 '� _e� - %\4LIw �t►+/�u <br /> �+hn. i� � �'•-L�v�,c..,c_ �l <br /> t iY-t a)w�-- C-t 1 Dom•S;•k--i� ivy �—V <br /> �L <br /> � ���u�•L-�-S 'b1f.�t. `1M �� � I�.a Q�}-�• • 1 i�' � ct.c-�.- <br /> tnu <br /> Inspection Form Included: 0Comments nclu d. 0 iness Rep's Phone Number In tot's Signature Phone Number <br /> INSTRUCTIONS ON BACK rOiill � )f1tl'f'S3 ��E_?C��t�hk�P�� �i^1; � 62081 <br /> iWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA Entered <br /> I KB <br />