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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California El <br /> MW Cgr to 181(New04104) Survey Form - Page 1 11 1088094 <br /> California Integrated Waste Management Board <br /> Part A- Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L1 - Inspection Type (Fill one) <br /> Site Suffix: 1 O �j O l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1�l�or�Jo #tkLc <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 1 O AM � i O AM <br /> I� 'n L ® PM O ® PM <br /> 129 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 5 ® Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude - O End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 /> Part B Inspection of Waste Tire Dealer,Generator, Hauler and End Use Facility ENFORCEMENT STATUS h <br /> O O HAU§ING,AND MANIFEST E491REME. S ' , p _ Q NoOhti <br /> "� ttce Vio a o Q Extension: <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance adline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB ;or60 <br /> utredVr <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years s q <br /> O O i 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersQie.ferred"CWM._,,,,)-_Enforgami;ni"�.A <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' <br /> ®;In Compliance N6`Violations <br /> �:�-: - -•iii'-` ,.i'i°: r•, <br /> O Q Other: § <br /> Comments <br /> !Inspection FormIncluded: Q <br /> LComments Included: ® 9 .yg� 73 <br /> _ sines,Re I ure Phone Number Inspe t i SI atu a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK -- --.t: correct: E K R M P L E 1 2 3 <br /> White Cop .CIW Yellow Copy.Operator Pink Copy:LEA <br />