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Waste Tire Survey & inspection Report Inspection Report Number <br /> State of California <br /> CIWMB181 <br /> asteManage Survey Form - Page 1 12 - 1 01 4 735 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + Inspection Type (Fill one) <br /> Site Suffix: 1 C7 7 1 G © / Q Routine ® Re-inspection Q Referral Q Observation <br /> Local j,. If Referral,choose referral type(Fill one) <br /> Identifier: QCHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Other <br /> hfpGr,�„� <br /> jBusiness or Facility Name <br /> � y Inspected By Inspector <br /> f2ec <br /> Physical <br /> Inspection Date / 0 <br /> 7 I �( <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> . Q PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' © 0 Active ®Passenger ®Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler ®Indoor <br /> Q Q Inactive Q Truck <br /> Longitude - Q End-Use A Container <br /> Q Planned Q OTR <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 /> j ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Nictation <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires EtttehRlcl '. <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance. Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pato <br /> Q Q 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required fpr 11fQV4t?��. fy� <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 Q.RNfel'rred!OWAIREnft1l40fljPi x''y <br /> Q Q 14 CCR§1$461 -Manifest System Requirements for Waste Tire End-Use Facilities X <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> � Q�Ili Cottipll8tt�l - ���V� ,r <br /> Q Q .Other: § <br /> Comments 'RA bti%$' L 5j. GTcJ now-1 �ti7�t/�2 (i{e7s+�• �s�,Y <br /> 5 1 r• -{�.a- res O D b-f�4�r,.��.. �„k+s �- Gktti la.- �s 7�t <br /> (r± P 1 � <br /> -Gr Is7/Y4iu— 9 �Jtel6+'^r <br /> Inspection Form Included: Qi ��� 2;Z <br /> -1- <br /> Comments Included:40 �/`�r ✓ / T(7 <br /> 1 Business Rep' Signature Phone Number Insptoes Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorroct: `h lw�J E X A h� P <_ t 31 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />