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rn <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Slate of Califomia <br /> CIWMB 1III egSurvey Form - Page 1 1 5 - 1 0 1 3 0 2 1 <br /> California Integrated WastastManagement <br /> Waste Managee ment Boartl <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Liy <br /> Site Suffix: I 3 ! Co s 0 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> � <br /> Identifier: (� ,fdCL� Q CHP Q CIWMB Q Complaint Q Educational Visit Other <br /> Business or Facility Name <br /> Inspected By Inspector , <br /> a I rte COvi crefe- P,-�C+s <br /> Physical A dress 3 <br /> Tyra C Inspection Date Q <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> _ 0P --- 0P <br /> i J��+ VH✓ `/ ��R�Z�C Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W holelPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude - I Q Hauler I Q Indoor <br /> O Q Inactive ®Truck <br /> LongitudePlanned OTR <br /> i- End-Use Container O ® <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Lp Service Station Q Hauler Q Agriculture Q Shredder ®Other Nme.& PrOcLi <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility_6 WON1PORCMENT`SfiATllS .. <br /> ` '4 � `'' ""' "` Q Notice Of Violation Q Extension <br /> Q Q I PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> Q O PRC§I42956-Registration/Decal E in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> �� rs <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days avor EXT) <br /> O 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 00 '14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement J <br /> '. <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ® ,14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �a fo Com Ilanoa <br /> 010 Other: § �+ P ratians <br /> CommentskbL Iws ttl:Yl T�U5 c� E,.�Vti?'11DW --. iAAC.S f1CIE'CX f _� 1 <br /> _a,.4+4ups l�,)►( LL'ct�J �iY tcl.._�S.SL�.4c�c�b �' ` �- ltt ._ C <br /> -�11VLIl'•Z 5 <h� C-i 1_N16�tii.}:� fis `K�►"� r�S Srhlt,�c�j Gl.bu=�_��'1`s_ t�'�w*, �iI) <br /> co, ILS-(1-<kVW:)_ 0 r, _ua_fiYf > X <br /> Inspection Form Included:Q 1 <br /> Comments Included:Q �` �'sSiig..I'ure <br /> Businephone Number_ In or's i ature Phone Number <br /> ■ INSTRUCTIONS ON BACK �� IEJX A MIPILIE1 IIf2I3I 62081 <br /> White Copy:CIWMB Yellow Copy.Operator - Pink Copy.LEA ® ■ <br /> 0633304.0092 <br />