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Jun-26-2006 09 :49 AM CA Int-cirated Waste Management 916363 1/3 <br /> Report Inspection Report Number <br /> Waste Tire Survey & Inspection Repo ■ <br /> G7C <br /> NU <br /> State of California i" <br /> Cgrated 9st(Now Manago) Survey Form - Page 1 .1 9 - 1 0 4 3 5 01 <br /> California Integrated Waste Managoment Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: O l , Q Routine ® Re-inspection Q Referral Q Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- - <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In (f Time Out <br /> Business Rep Title / f /V h 8 AM 0 AM <br /> TJ4� C�PI� 0(j(/d(Xj1__ i a 0 PM _ 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ? f <br /> Tire Count(Whole/PTE) D 7 s— (Fill one only) (Fill all that apply) (FII all that apply) (Fill all that apply) <br /> 0 Active ® Passenger la Generator Outdoor <br /> 0 Q Closed (,Altered <br /> GPS Latitude ® Hauler Qd Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - End-Use Q 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 /> 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 mao lis fyU. 6r 441:z'v`- /1 <br /> al <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violat(on (b Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance--D6adline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I <br /> M . (� <br /> 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 {f�equired foi NO or EXT <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 Referred!C{WMs F�nffsreement <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 <br /> Q Irt L'bmpliaitce Ma Vioiatiofts? <br /> Q Q Other. <br /> Comments_ <br /> - <br /> Inspection Form Included:® �/1 ,J'� L� <br /> Comments Included:® a <br /> Business Rep's Signature Phone Number Insp or's Signature. Phone Number <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK .Correct,i lnct�rreet _ ( 13 JAM P ..!< la. 3 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />