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i� <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> ClWMB asteManage Survey Form - Page 1 1 2 - 1 0 2 5 7 9 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` _ O Inspection Type (Fill one) <br /> Site Suffix: C? 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P ysi al Address `` - L k <br /> 00 W Li voe— <br /> Inspection Date '5 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t 0 Active Q Passenger ®Generator Q Outdoor <br /> C I Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q Now Tire Dealer Q Auto Repair • Trucking Fleet Q Government Q Retreader Q Dismantler Q The 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENNN 1Kt M-PNTATATU3_.___-_____ <br /> ?, <br /> W-1 A: I MAl)tlNfl AND MANIFEST REQUIREMENTS. <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0. e' Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C911 Sr ,Ij a PeadlIke <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements E41' / ITI / M <br /> Q Q 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 (Rogt#red fPr NOV or EK7) <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 HaulersQ d t CIW I Enforcement <br /> 'J t <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> v <br /> Q Q 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § -_�1SfU4`r--No Vlgtitttlafle---.-- <br /> Comments Q_� lA rQ - ��^ `hpa��./rl `�/�71� \Aj <br /> wase \'res �.1 ryvnat- N-�NV A�5 t eel,, - v wpf� _. <br /> Inspection Form Included: 4_ <br /> Comments Included: - <br /> B mess ep's Sign re Phone Numbers In re Phone Number <br /> INSTRUCTIONS ON BACK Carredt� ' lftftT�"ACfr v1 �E M i_ - 123 62os� <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA <br />