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= _ Waste Tire Su- :y & Inspection Reporminspection Report Number <br /> iilll State of California <br /> �r CIWMB 181( e ) Survey Form - Page 1 1 7 - 1006 0 0 2 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � O i Inspection Type (Fill one) <br /> Site Suffix: J 7 ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5MA _� DAq h tt V� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspe or <br /> Wct c'l ` l ,.� kc v�w� �j i�'c�,r L <br /> Physical Addr welffiguipw <br /> , p <br /> Inspection Date ( t V <br /> Time In Time Out <br /> Business Rep r Title ® AM O AM <br /> O PM , � � � 0 PM <br /> Operational Status <br /> Fill one only) Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5 !'� ( y) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> f ' J # Active ® Passenger ® Generator to Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> 0 O Inactive Q Truck <br /> Longitude - O Planned Q OTR ® End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> o New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station ® Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ _ <br /> I V ' A HAULING AND MANIFEST REQUIREMENTS <br /> , � Notice Of Violation Q Extension <br /> 0 O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O ® PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXE <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O ® 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB .Enforcement ; <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O _- 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> O 0 Other: § <br /> Comments p f <br /> l.v s-t-� rt tt�'� �[' �`%c GM _CMS 5 ---`Y'�cc-►�r� �c-1 CAA 5c <br /> il,; ,�� l t�- ' r� s 5�,�,t.� `���� C t�c.lti-t,t�o �cu � <br /> - - v <br /> u --ob��`�--� -� 1�o t Wit~ u t� S <br /> VA Ck <br /> Inspection Form Included: 01 a <br /> Comments Included: 0 --- - ig - -- - - - <br /> Business Rep's Signat r Phone Number �klnector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct - IncoFrect { �',X ft'1J1 P L 1 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />