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Waste Tire Su y & Inspection Repo Wi e-ction_ Report Number,_ <br /> State ofCalifornla Survey Form - Page 1 I $ - 4 Z 5 $ 5 9 \� <br /> CIWMB 181(New 04fg4) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PA <br /> Business Profile Inspection Details <br /> 7PID- Inspection, r � � _ � � Inspection Type (Fill one) <br /> It � <br /> Site Suffix: 4�- LJ- ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> cry h C7quH�rti <br /> Business or Facility Name / <br /> Inspected By Inspector <br /> Physical Address 9 <br /> Inspection Date <br /> L.", <br /> . " , lt� �52_42__t Time In Time Out <br /> Business <br /> Rep <br /> Title � AM O AM <br /> QPM O PM <br /> Operational Status! Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ' ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive *Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other �h /✓ - C�,y�` rs. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING.AND MANIFEST REQ.U.IREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. �, <br /> 0 ! � _ C mpllance [leadllns <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requiremei / Qatg l I f I I <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program (D Number from CIWM `(� <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire rip s wit i 9Q day 111 (R9qu1red for NQV or Ek 0 <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Tr' ogs f r <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Ti r Hat?leS�ferij��i 1 CIWMB -Enforcement <br /> 0 0 ; 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 i 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1ftomollanc No violations <br /> Q 0 Other: <br /> Comments � frf� GQUC� �-,.�� �tShq�2.- . -'�/'jam D►'_.._.r�.'�! -T'�v,,�-S' o �YL,r2- -- <br /> -if t.-..0/.s 1'eG,•,-vv -�i'��.— l7`z=- !+� .� AS4- <br /> 7L..) Va�A <br /> 'T/ r-s <br /> .Inspection Form.Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature PhoneNumber I Phone Number <br /> _ l T 62081 <br /> INSTRUCTIONS ON BACK <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />