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4i Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Statoof181(NfOla Survey Form - Page 1 1 - Q 2 5 7 <br /> CIWMB 181(NOW M nage) Y <br /> California Integrated Wasto Management Board <br /> 31 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> !Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: QCHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> WC_,,Pe_ ��, _ <br /> Physical Address 3 <br /> 7 77 <br /> Inspection Date <br /> /4J t7 Time In [ Time Out <br /> Business Rep Title Q AM O AM <br /> O PM O PM <br /> f {� ✓�/ /�"t Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (7 ® Active Q Passenger ® Generator Q Outdoor <br /> Latitude <br /> Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> o Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 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 Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility { ENFORCEMENT TATUS <br /> HAUVMG ►¢4iltIkN[F`k$ `"I� GIIIMLh1fs <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q NOtige OfViolation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. CgittplhApC� pptl�llta <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirementsa�e , <br /> Q 0 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 fR90Md ft3rNOVOrOM <br /> O Q 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 0 114efbfl d!dlWMIIIEnforeement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' <br /> V <br /> Q 0Other: § i Y� tltltGll ► D tdletintt� - <br /> Comments <br /> entM 6Lot n�y�Lo�-1�t'7 l � PLIII� <br /> � t'a��'►�"` v��i 11.0 <br /> Inspection Form Included: Q <br /> Comments Included: (� <br /> "Business Rep's Signature Phone Number I ct Phone Number <br /> INSTRUCTIONS ON BACKyNE C AWI F' I_ E I 2 ,3 62aa1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />