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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Skate CIWMB <br /> 181( rola Survey Form - Page 1 I - 10258 9 <br /> CIYYMB 181 New 04104 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection� � � — � � Inspection Type (Fill one) <br /> O � <br /> Site Suffix: IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> 1 Identifier: l! '(utabVAkj <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business <br /> or Facility Name VVVV V—f((�/ �/ i Inspected By Inspector <br /> /� <br /> 11 7 Ii�Q�j 1'r I �W , U' G• rx <br /> Physical Address <br /> 3� 9 Ad A- -4. �ot - <br /> _ ^ _ Inspection Date f i'" <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> `!. Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger # Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® 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 /> Service Station 0 Hauler 0 Agriculture 0 Shredder ®Other ,/vluhieSprts Valtde,'�t.f4,[ t'r <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility 9NFQRCEMENT:STATUSA. _ <br /> I <br /> HAULING AINDjV1ANfFEST REQUIPtMEMTB <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice of Violation 0 Extension <br /> 0 0 j PRC§42953-Contracts with Registered Waste Tire Haulers. Compllance..Doadline <br /> I <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Requked!or NOV or EXT] <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§1846D.2-Manifest System Requirements for Registered Waste Tire Haulers Q Refitlrf' d!aIWM� �nfofcement <br /> I <br /> 0 0 114 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 ( I _y Flo VloiaHon� <br /> 0 0 Other: § <br /> Comments JCo� wa5�e -firs rvtrt �5�5 (Jh S 1 bQ <br /> u,) Act I L4S ✓e 5 60ueA Rt-1 gy-af GfS <br /> 6wash fZre2 S j2vel-y 1- mohikS . Tres Stored o /l+,fetoors on, rnck_-s, srt,cr�e- <br /> f� w,ai4j .5f S c►>`sr.te. �r v-s, Mat -5t�✓v TP I b* a I I <br /> W1o►hiFests. <br /> Inspection Form ncluded: 01 <br /> ncluded:Comments i - <br /> 01 Busines s Signs Phone Number <br /> ture l`{�Phone <br /> � <br /> NumberSigns <br /> INSTRUCTIONS ON HACK M Cl1FC1lttll}"J`+A# /' � _ �i11P i I� �1- 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />