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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMB <br /> 181( rola Survey Form - Page 1 f 9 • Q 6 2 <br /> CIWMB 181 New nage <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK_ PEN_ <br /> (Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1+ Cj Routine Q Re-inspection Q Referral Q Observation <br /> Local �—v _ If Referral,choose referral type(Fill one) <br /> Identifier: ���hr� �'� fy (�ff p ';OCHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - Inspected By Inspector <br /> 7 <br /> Physical Address <br /> / C73 r /-I f At r— 5-f <br /> Inspection Date � (� I '2, <br /> Time In Time Out <br /> Business Rep� Title 0 AM Q AM <br /> O PM O PM f <br /> Operational Status I Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> t (9 Active ® Passenger 0 Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 ENFORCEMENT$TATU8 <br /> V! A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation r1 <br /> Q 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires l `;Eistepsh7lt <br /> Q O .PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Requlred for NPV tires <. <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days yi <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I +' �""`✓� <br /> O <br /> 14 CCR§18460,2-Manifest System Requirements for Registered Waste Tire Haulers Q.ftefarred F t31WM8 E11ir�l�$,Ai94�ls� <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' y <br /> O Other: § <br /> Comments ka- C'( ,�G> /1C�S' �(U��,P �71`t���G �✓G7(.� ( r1rCt tn�iP� �f T'C_ <br /> �C 1 u- L�1ZC) �GN(� f �L/f5r+.��- 1 �[��vtr�•s ��U (,��s,�z= <br /> Inspection Form Included: ® <br /> Comments Included: ® v �L/�J7 <br /> U_ ep' Phone Number is Sig a Phone Number <br /> INSTRUCTIONS ON ACK Clrre Incorrect: ,q ,�, p L t 62081 <br /> tMered - - - �- - )- L� <br /> KB White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />