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im <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState California <br /> Survey Form - Page 1 1 4 . 1 Q Z 6 9 <br /> CIWMBB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> I TPID- � � � Inspection Type (Fill one) <br /> Site Suffix: L�— `� <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local ,r- If Referral,choose referral type(Fill one) <br /> Identifier: N � � r�y �� 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / ; Inspected By Inspector <br /> lel \jJo►-�s <br /> Ph%)Ci2l Address 7 <br /> l _ Inspection Date [� O <br /> Time In Time Out <br /> Business Rep Title AM O AM <br /> / 0 P 0 P <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) j <br /> ' O Active Passenger A Generator Q Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — Q Planned Q OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> IS New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> j Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> i <br /> 0 Service Station Q Hauler 0 Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS. <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation 0 �Mtgtlsl.AE1 <br /> O : O I <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m ;' <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Onto <br /> Q 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program iD Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Ri3quJred/o�NOVaIX1"} { <br /> O 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ' <br /> f <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers I 0 R9ferred 101will hnfpfl3Nt)tl(J1Y <br /> O O : 14 CCR§ 18461 - Manifest System Requirements for Waste Tire End-Use Facilities _ y <br /> O O <br /> 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> IR �'taltt�ll5f100 Y Ifl.4 Vlet,�tl�"��shy <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: U� <br /> Comments Included: Q <br /> s nes phone Number Ins cto s tgnature Phone Number <br /> ZN <br /> INSTRUCTIONSBACK I Correct:9 Incorrect:' ( JE �J A Ohl P I L I E; 62081� 1 ; 2 13 I <br /> Entered White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KB <br />