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` r } 4 A <br /> 1. 'nspecttort Report Nt�rnber <br /> Waste Tkd SuTM_ y . Inspection..Repos}._ <br /> E1 StateForCalitornla --- _ - {{{{ .'. tJ'�j !f� �/''�J <br /> CIWMt3'18i(Newaf04i.1 c.Sur,rey For.m�--;:Page '1 :: i - - - M- .i. •: �+;- <br /> .,. :} <br /> Carforiniaintegratedwaste,ManagementBoard - BLUE OR BLACK.INK PEN <br /> •.Part.A Surv . <br /> TP3D ""Type (Fill one) 4 . <br /> Site Suffix: ® Routine Q Re Inspection Q,Refe'rral Q Observation <br /> Local ` <br /> if Referral choose referral type(Fill ane) <br /> ldenkifier: gf CHP Q CIWMB Q.,Complaint: Q Educational Visit Q.Qther, <br /> Business or.Facility Name: InspeGfed By Inspector <br /> Physical Address <br /> y <br /> Street inspection Date ' <br /> �. a s . <br /> Time but <br /> City :• stafa Z1PCode Time In <br /> Business Rep i. Title 0 Alvl Q AM <br /> OPM. PMi <br /> r' Business Role ' <br /> Operational Status <br /> (Fill one.on (Fill all that apply) <br /> _ f <br /> I &Active ®-Generator <br /> r <br /> r O Closed 1 r <br /> ,GPS X,atitude O Hauler <br /> f � Inactive _ <br /> F' ° Q End <br /> Longitude — Planned , <br /> 1. <br /> 1� <br /> Q New Tire Deafer Q,Auto Repair'.: ® Trucking Fleet'- (D Go�ernmertt _Q Retreader Q Dtsniantler :,.0=7iYe Derived Fuel <br /> O Used Dealer Q Auto Body Q Car Dealer Q Collection b Crurrtb Rubber <br /> µ r Shredder M. <br /> Other <br /> Q Service Station Q Hauler Q Agncultur� Q,. O <br /> Part B Inspection of Waste Tire Ibeater;Generator, Hauler and End Use Facility N RCEMEN �STA7llS <br /> " VM• " .:`Hi4lfl=ING;.A D' !N1FE51 r ftp_' iREMEN;;S ter" w;: a ' " s em bg , saon �p <br /> _ -" a Nottce'Of d/tofatton ., I�xtenstonx <br /> O 0 RRC§,42951°—Waste Tire Hauler Registration and Transport of TiresIj <br /> O O .PRC§42953 :Contracts wikh Registered Waste Tire Haulersan <br /> Cvmpffaiiee�Deadhne ? ,,r, <br /> Pf2C 42956 RegistrationlDecal in Vehicle <br /> 14 CCR'§ 18459 .Responsible'E titles Complying with Ma'ntfesting Requirements ate c <br /> 14 CCR 18459 1 a t7 c Tire ram ID Numberirom-CMMS "* <br /> (Regttrre4`for�lOV�gr_EX7};;�� �. [ <br /> O .O- 14 CCR§18459 2 1 Submittal of Manifest Forms•and Tire Trip Logs within 90 days <br /> 1 CCR 18459.3-Retention of Mai nifesi Forms and Tire'Tnp Logs.for 3.Y <br /> ears <br /> O \. 14 CCR 18460 2 Manifest System Re uirements for Re istered Vtilaste Tire Hau#ers �t�e e`rfed.G41NMBIpfercerngnt. =� <br /> O O § y q.. . ' g , <br /> 14.CCR 184613 - Manifest S"stem Re trements for Waste Tire,End Use Facilities <br /> ^14 CCR§78462 Manrfest�Syste Requirements for Tire De'alers or Waste Tire Generators -- <br /> O !TI { plfapice�l iirll�itl4ds <br /> Other-'§ P n` <br /> "Comments = t <br /> I ' <br /> I <br /> I <br /> ,•, r ,62081 f' <br /> INSTRUCTIONS ON BACK. 'r,ec � icorrect , F til P. E 1 2 3 # <br /> ■ White Copy;CIWMB ; Yellow Copy:Operator `Pink Copy:L" R <br />