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Waste Tire Survey & Inspection Report Inspection Report Number <br /> • <br /> State o/California Survey Form - Page 1 1 9 - 1025730 <br /> CIWMB 181(Now 041041 <br /> California integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> iBusiness Profile_ Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHIP Q CIWMB 0 Complaint O Educational Visit O Other <br /> 1 Business or Facility Name _ Inspected By Inspector <br /> 4 Physical Address / �QSfe eer%.$ <br /> SDS 5- At, 1 <br /> 1 <br /> Inspection Date Lf <br /> /'7 ✓ ` Time In Time Out <br /> Business Rep Title i O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I(Fill one only) (Fill all that apply), (Fitt all that apply) (FM all that apply) <br /> t r • Active Q Passenger { ®Generator ® Outdoor <br /> D I O Closed Q Altered { <br /> GPS Latitude 1 { Q Hauler i Q Indoor <br /> � Q inactive i ®Truck <br /> Longitude - Q Planned I Q OTR O End-Use I Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauter O Agriculture Q Shredder Q Other <br /> (Part B-Inspection of Waste Tire Dealer, Generator,Hauler and End Use Facility iwPIFQI%E�NT-BTATU3 <br /> r _ ^. .� <br /> Ott <br /> 14444NI A NII 110h $T RI!{dkilR Mt:N1�8 4 <br /> 0-111119_1110V Violation O Extension i <br /> Q O f PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 1 <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O ( Cotnplieinca tirwdttnt� <br /> Q I Q PRC§42958-RegistratloniDecal in Vehicle <br /> Q I Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements - <br /> O Q 114 CCR§ 18459.1 (a)(b)(c)-Tire Program(D Number from CiW MB y I V <br /> O O 114 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R6QUlmdaorN0lf or EX7) 1 <br /> O O 114 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 Hau4ers 0. , ,l:�s{"lftsr�emaRt <br /> o <br /> O O {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 /> Pig Other: § I <br /> Comments �// f t•�_ I ��/HG ��"'�y �%�G�iTt. /�1CG��IG�G�ff2� W�'� �C.�IC.' <br /> Inspection Form Included: Q - 76,�'s <br /> Comments Included: Qom- - - <br /> Business Rep's Signatu a Phone Number I Phone Number <br /> INSTRUCTIONS ON BACKi' C�II ' [� j '!f a P! -'1712- 3 62081 <br /> White Copy:CIWMB YWIoW Copy:Operator Pink Copy:LEA <br />