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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callfomla <br /> CIWMB 161(New 04104) Survey Form - Page 1 , - 1 0 1 3 5 4 0 <br /> Caltfomia Integrated Waste Management Board BLUE O EN <br /> Part A-Survey -- - <br /> Business Profile Inspection Details �H_ RMI-8 <br /> Inspection Type (Fill one) <br /> Sit Suffix: Q �ou Q Routine ®Re-inspection Q Referral Q Observation <br /> Local type If Referral,choose referral (Fill one) <br /> Identifier: ��" - �/�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name —� Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date <br /> -- `��571 Time Out <br /> City —mate Zllode Time In <br /> Business Rep Title mm O AM O AM <br /> 0 PM �' 0 PM <br /> I�D. s �Po----- J- OWE— t <br /> Opewtiona{Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill ell that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r r Z O',Q <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> 0Closed 0 Altered <br /> GPS Latitude Q Hauler O Indoor <br /> '0 Q Inactive Q Truck <br /> Longitude - I Q Planned Q OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Used Tire Dealer 0AutoBodv Q Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I _ J <br /> Part B-Inspection of Waste'Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Deism <br /> m <br /> O Q 14 CCR§18459.1(a)(b)i�c)-Tire Program ID Number from CIWMB <br /> O O — (Required for IYOV w EXT)- <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Fortes and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manliest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities - - - - - <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O Other: <br /> Comments �t ; :Z, rdt Sr'/� or--� 'Tb+e _2�7_f� <br /> y47 ^_0 <br /> Inspection form Included: i 'YC�D-Zq�jb <br /> Comments included: B s ep s tgn hone Number I tor's Signature Phone Number <br /> -- ?� 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect:Rf&9 E X A M P L E 1 2 3 © ■ <br /> ■ White Copy:CIWMB Yellow Copy:operator Pink Copy:LEA <br />