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48129491094 ■ <br /> Waste Tire Survey.& Inspection Report Inspection Report Number - <br /> '° Statae 181(Nr Survey Form Page 1- 1 6 - 1 0 1� 0-8 6 1 <br /> CIWMB 191(Naw 04/04) <br /> Callfomia Integrated Waels Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- / Inspection Type (Fill one) <br /> Site Suffix: ®,Routine Q Re-inspection Q Referral Q Observation <br /> Local57�jIf Referral,choose referral type(Fill one) - <br /> Identifier: z p2Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I ® <br /> /93 7 — <br /> Street <br /> Inspection Date <br /> City State ZlP Code <br /> Time In Time Out <br /> Business Rep Title Q AMQ AM <br /> QPM m'm 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger ®Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 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 /> I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC--EMENT STATUS <br /> V A HA LING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Q <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements 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(or NOV 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 Q Referred/CIWMB 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 C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments �1 Y� trli'Re w�r 4A-0 ' <br /> �ae.�ei�1y date rtio� S-d!-� ty // •� 5'S�-�, a wort 9'c�e�/ <br /> cLe �• 3 <br /> Inspection Form Included:Q <br /> Comments Included:Q - � Wk <br /> Busl�Renature Phone Number Inspector s Signature Phone Number <br /> INSTRUCTIONS ON BACK 1E X A M P Li1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />