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Waste Tire SuryInspection ey ,& Inspection Report <br /> State of California - <br /> Cgrated Waste <br /> eManag4) Survey Form - Page 1 I I 8_� 1 0. 0 6 4 0 8 <br /> Callfomia Integrated Waste Management Board - <br /> Part A-Surve BLUE OR BLACK INK PE_N <br /> Business Profile _ - _- _ - Inspection Details <br /> TPID- e� Inspection Type (Fill one) <br /> Site Suffix: 3 6 G _S j "C D I ®Routine Q Re-inspectionQ Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other I <br /> Business or Facility Namep <br /> • J To�-1c.�••p ['e r Inspected By - Inspector ' <br /> Physical Address <br /> �1 \•) � ` .-__..---I --__: .. ., 1.�; � ._1.�.d.:_l��o�-fad- . <br /> f/} Inspection Date 0 <br /> o �ow 5� D <br /> •�c Time <br /> In Time Out <br /> Business Rep Title i O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fillall that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Passenger 0,Generator Q Outdoor <br /> 0 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 (FIII all that apply) - <br /> Q New Tire Dealer p Auto Repair Q Trucking Fleet p Government Q Retreader p Dismantler Q Tire 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMFNT <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires ottee Of Violation Ex <br /> Q Q § 9 P �� <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cornp!lance Deadline w <br /> Q Q PRC§42956-Registration/Decal in Vehicles , <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB , r <br /> Q O , <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days �.,�.x ; � `:� ='•:vs <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 Haulers : <br /> Q Q 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 ;N <br /> Q Q Other: § <br /> s8 <br /> � 1Comments <br /> ,��••�.i - <br /> _ '' tA- <br /> AIX <br /> lS-,_ l�ctll s Y rt�y]� itn�to t %lens t� <br /> [� �1 <br /> Inspection Form Included:Q <br /> Comments Included: --- X02. ---��rl �� <br /> Bus19 1`1 <br /> t s Rep's Sign ure Phone Number I i_ Phone Number <br /> +;��•':�,:.•-. "�� �� '' <br /> INSTRUCTIONS ON BACK62081, Et" R M P L <br /> a� to <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA - ■ <br /> 0525804.0163 <br />