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08038040318 <br /> ■ .-rir <br /> t Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ <br /> CIWMB <br /> S.urVey.Form - Page 1 ...I�. 4 -- 1 .0 1Q 8 .3 5 <br /> clwMe tet iNew oawf <br /> cakfomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / / O / Inspection Type (Fill one) <br /> Site Suffix:. i S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier: �k �fJQ��/l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name' <br /> Inspected By Inspector <br /> Physical/Address <br /> I ?XA6 <br /> Street 4 Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title _ - r O AMFTI Q AM <br /> :MOPM 0 PM <br /> I— (W )a e`e�t Operational Status Tire Type BusinessRole Storage Type <br /> Tire Count hole/PTFE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active •Passenger ®.Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m• Q Hauler 16 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 40 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. I <br /> Part B Inspection of Waste Tire Dealer;Generator,Hauler and End-Use Facility _ENFORCEMENT STgT1U_S <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of 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 Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements. Date m / m / m <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 for NOV or EKE <br /> Q O -- <br /> 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 Referred 1 -tWMB Enforcement <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 In Compliance - No 1/Iolations <br /> Q Q Other: § <br /> Comments <br /> (f 72 Y�"t.✓�� u .o�+ /e ms`_ u' � 1 <br /> Inspection Form Included:Q MC-k >� <br /> Comments Included:Q <br /> Business Rep's.Signature _ Phone Number Inspector's Signature' Phone Number I_ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X L M P E x 2131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />