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Waste Tire Sur*y & Inspection Report Inspection Report Number <br /> StatCIW afCall(Naw I Survey Form - Page 1 i 2 - 1 0 4 818 <br /> CIWMB 181 New 04!04 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- +Inspection Type (Fill one) <br /> Site Suffix: { �f — 01 !® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: :0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Bu ness gr Facility Name Inspected By Inspector <br /> Physical Address <br /> _ Inspection Date p <br /> � � UY�r�✓� VT l � %�� <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> I S7 ✓� � 0 PM O PM <br /> VWOperational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �1 <br /> 40 Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Altered <br /> GPS LatitudeQ Hauler Q Indoor <br /> I 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ;�N1=QRCkMENT...m_..._._ _ . ._ __.._._...._..... <br /> . STATU5_... ! <br /> V' '�A HAULING AND MANIFEST REQUIREMENTS. Q Notice t31 Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Wadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate. / m I FT] <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB [E <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days R.6gUlred forNOV or <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 01W.Ms 8nforcan*nt <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 /> �ln QptClpH�ni�- Ng..1ll¢latllts _ <br /> Q Q Other: § <br /> Comments VO r t—tVVL�'Vvk- V Y"L>U VL`"-k <br /> v <br /> Inspection Form Included; Q <br /> Comments Included: Q V`�"� <br /> Bu ness Rep's Signatur Phont9 Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK �Carreet` CC A=Wt�P1'l� f �t i41 <br /> 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />