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=a 9. �spection Report Number <br /> Waste Tire SuOW & Inspection Report <br /> rni <br /> State of California <br /> ;st Manage, Survey Form - Page 1 1 5 - 1006454 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i f - ( Inspection Type (Fill one) <br /> Site Suffix: 19 ® 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 <br /> Inspected By Inspector <br /> �J < <br /> Physical Address �I <br /> / ,� ! Inspection Date / 1 © -7c�� �{� >ZT� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / C) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger 0 Generator Q Outdoor <br /> D Q Closed Q Altered i <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rT!;11,1 �r,w !A710, <br /> PRC 42951 -Waste Tire Ha , <br /> Q Notice Of Violation Q Extension <br /> Q Q § Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m �1 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB f <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 daysI '(required forNOV.orEXT) <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 0 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 t a' <br /> ions <br /> Q Q Other: § olat <br /> Comments <br /> ��- ( ;r-r�1�- ref-�ti��s �r...o✓mss �-..��r �ir�s �v�.. <br /> l <br /> L..�i/�►`/' n� � �, G/�l r rNr..-s�.�'�-� �7i S '!l y'__h4 _7/757/, , <br /> -7 <br /> l�v�a77►v.e fi/-�5 <br /> / / / , „, I/Z--&,, <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number <br /> or's Sign ure Phone Number <br /> INSTRUCTIONS ON BACK ; Correct a� cncr'T I A IMI P I L I E 1 111213 62081 <br /> Ejagii <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />