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Waste Tire Sur ,-y & Inspection Report Inspection Report Number <br /> fo <br /> CIWMB 81of 1i(N(Now Survey Form - Page 1 1 7 - 10 2 5 8 5 0 <br /> California Integrated Waste Management Board <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> 'Business Profile Inspection Details <br /> TPID- Inspection� t L � _„ } r � ' Inspection Type (Fill one) <br /> Site Suffix: '�C f Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: � �� Cu 11 Q CHP Q CIWMB Q Complaint Q Educational Visit Q other <br /> Business or Facility Name `t ✓ <br /> Inspected by Inspector <br /> Physical Address <br /> I <br /> Inspection Date © �e� / 5. 05. <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM(" J Operational Status Tire Type Business Role ' Storage Type <br /> Tire Count(WhofelPTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> � � <br /> • Active Q Passenger ® Generator 0 Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned IS OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility I NFORCEMENT STATUS <br /> A' l HAPL IHt3 ANR z PAN P.41T REOUIF MENTB Q Nattcx.Of Violation Q Extension <br /> Q Q 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Readlins <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I 1 { <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RQt{UJrtetl.fofN.DV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years — .T <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q f#,efwrred/CI4V�A>ESE EMtfetnent <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> QO 14 CCR§1 tvManlfa—s ysfS TMTrRequirements for Tire Dealers or Waste Tire Generators <br /> O O ;( iY>1{tPAi ;� Stialstl.onts <br /> of : § .�^c� ] �y /) <br /> Comment 40 �4— 7 " ! �Z5T1s �l' �--f�.c,S) �/� �'� G <br /> �1 r� ��fc� �w�� 'rte� aim l��� �� wta�7�• ->�i'r�s' wrt S <br /> r-r,ot,ej -(7m,..-- 41.2 s� � ®r-. ,t�f ns10�-1-_ ►✓1 M ` _' /6'7 5.5-7 3 <br /> Wt <br /> Inspection Form Included: <br /> 1 <br /> Comments Included: <br /> Business Re Signature Phone Number I ec or's igna a Phone Number <br /> c _r�_ sT. LZE <br /> _ _ _ _ <br /> INSTRUCTIONS ON BACK GQi<P � t ,, j 62081 <br /> Copy: <br /> White Copy:CIWMB ,Yellow Copy:Operator Pink Copy:LEA <br />