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E'7 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Staleof61(New ) Survey Form - Page 'I i 9 - 1025870 <br /> CIWMB 181 New 04104 <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> { TPID- / Q © inspection Type (Fill one) <br /> `I Site Suffix: 1 / 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> ` Identifier: LAi - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ��gSLj <br /> I,(r,c� G„ <br /> i <br /> (`e,� Inspection Vale (C) 3 / S / C� �, � J <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> ` ���✓ Operational Status Tire Type Business Role I Storage Type <br /> Tire Count Whole/PTE <br /> ) 2 5 (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> I <br /> Active ®Passenger S Generator Q Outdoor <br /> O � <br /> Q Closed Q Altered 4 <br /> GPS Latitude Q Hauler I Q Indoor <br /> O Q Inactive Q Truck 4 <br /> Longitude — Q Planned Q OTR Q End-use ® Container <br /> ` I <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 Lv'4411 <br /> Part B - Inspection of Waste Tire Deafer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V, J.HAU ANIS MANIFEST R�GlUIRRMENTS' _ <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i'O Notice Of Violation Q Extension <br /> Q Q PRG§42953-Contracts with Registered Waste Tire Haulers. I!Compliance Deadline <br /> Q Q i PRC§42956-RegistrationlDecal in Vehicle m m <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements I Date I I l ! f ` � <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I l I I I <br /> Q Q ' 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> I : <br /> Q Q 1 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 114 CCR§18460.2 -Manifest System Requirements For Registered Waste Tire Haulers Q } 6f@rred/CIWMB EnforCemant <br /> 0 O ti 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 /> IQn Qerrtptiahge No Violstlane <br /> Other: § <br /> Commentssq4� <br /> Pl�l� Ly <br /> (Inspection Form Included: Q� L <br /> Comments Included: Q J �`'� �� — <br /> I Business Rep's Signature Phone Number/ Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK COrI'�Gt; �E~7( A ,MIIPi� 1_i �13J 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />