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Waste Tire Survey & Inspection Report Inspection Report Number <br />State of California <br />CIWMB18ast(New Manage) Survey Form - Page 1 1 2 -1 0 2 5 6 6 6 <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />- Inspection TypeOFill one <br />Site ffi0 <br />Site Suffix: Routine Re -inspection Referral Observation <br />Local <br />Identifier: <br />�J{��� <br />r Gi <br />Business or Facility Name <br />Physical Address <br />Business Rep Title <br />wry �jll �ar�P��r tars <br />Tire Count (Whole/PTE) <br />O <br />GPS Latitude <br />J <br />Longitude — <br />Business Type (Fill all that apply) <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By j Inspector <br />Inspection Date <br />Time In Time Out <br />0 AM 0 AM <br />0 PM O PM <br />Operational Status, <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />/® Active <br />0 Passenger <br />0 Generator <br />0 Outdoor <br />0 Closed <br />0 Altered <br />0 Other <br />0 Hauler <br />Is Indoor <br />0 Inactive <br />Truck <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />0 New Tire Dealer <br />0 Auto Repair <br />® Trucking Fleet <br />0 Government <br />0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer <br />0 Auto Body <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 Service Station <br />0 Hauler <br />0 Agriculture <br />0 Shredder <br />0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility I <br />NF.RM NT $TATiJ,8_...---._-..._....... <br />V - A HAULING AND MANIFEST REQUIREMENTS `! <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of TiresT Nptit Of Violation 0 Extension <br />I <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. Cq ItQq DBadline <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Data <br />0 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />RtZtllred fo'r NOV or EXT} <br />...... <br />.. .. - <br />0 0 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years a, <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers QtcfWfiB Enforcement <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators (^ ^M v <br />i� f llttnps .r No Violatlans <br />0 0 'Other: § <br />Comments �,4 C. Jt-'� i p S � yr (LA5 �,{) G, 'T <br />lrt�- j t.A � � � � f �U11%�a�tJ �'i✓� I ��J �S r I � � � [ ! 7j � �� <br />Inspection Form Included: 01 <br />l f�-2.?g6 <br />1 Comments Included -.0i I Business Re g;6 lure Phone Number I Insp or's WaturePhone Number <br />INSTRUCTIONS ON BACK /Correct, llncorroot, ( lv ( � A. P LtE �II2�3� 62081 <br />White Copy CIWMB Yellow Copy. Operator Pink Copy: LEA <br />