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« , Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callfornla <br /> Cgrated Waste <br /> Survey Form - Page 1 1 1 - 1 4 2 5 7 9 7 <br /> California Integrated Waate Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TPID- u y, _ O Inspection Type (Fill one) <br /> Site Suffix: C b y J 0 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 /> Physical Address 347 <br /> W L, <br /> Inspection Date Q / / 0 <br /> 1 C� 1'x.377 � � � <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T f V $ Active Q Passenger *Generator 1 Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O <br /> Q Inactive Truck <br /> Longitude — Q Planned j Q OTR Q End-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4k 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 ;.EN OI I RMENT STATUS <br /> .. 1 <br /> V I A i HAULING AND MANIFEST REQUIREMENTS <br /> Q Violation Q Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 1 <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cq. q Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dd 7. F,_7 , m <br /> 0 Q 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 (Reg4lred tbrNOV or EXT) <br /> •. t xr; . -— - -- <br /> Q I 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> S3 5 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q f�,aud(GlWhilB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 ! 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators j noel No Violations <br /> I !P <br /> 0 0 Other: § - <br /> --- — — -- — <br /> Comments � �� / i n .17► � L ��^ <br /> �k'� T-5 tna� or' 4 T}tar s aK OSt�. V-V l,-� Q �. 1 .50�� <br /> � y <br /> Inspection Form Included: 0 <br /> Comments Included: Q; ' <br /> sines s Rep's Signature Phone Number net Phone Number <br /> INSTRUCTIONS ON BACK Ctarreatr. lndoo;0`ct� !y �1 P j I_rT III 2�J 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />