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Inspection Report Number <br /> Waste Tire Suloey & Inspection Repor, <br /> StCalifornia Survey Form - Page 1 l 8 - 1 0 1 4 7 4 0 <br /> California InCIWMBWM13 181(Now 04104)tegrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ _ Inspection Details - <br /> TPID- 1 �tnspection Type (Fill one) <br /> 1 O <br /> Site Suffix: 1 ye J t Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 Q CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name V +/ <br /> Inspected By Inspector <br /> F11'c- , - P, <br /> Physical Address <br /> Inspection Date I J / ;,7 Q L� i <br /> cI�Z 15' i <br /> Time In Time Out <br /> Business Rep Title U AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> S o ® Active ® Passenger ® Generator Outdoor <br /> Latitude O Q Closed + Q Altered <br /> GPS Q Hauler O Indoor <br /> O 1 Q Inactive O Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader • 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 O Agriculture Q Shredder Q Other <br /> I +E3 <br /> Part B - Inspection of Waste Tire Dealer Generator, Hauler and End-Use Facility EN NT- <br /> V. A HAUL IINQ AND MANIFEST REQUIREMENTS <br /> y - <br /> Q No" � VCol�lon <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC 42953-Contracts with Registered Waste Tire Haulers. P #W�^r <br /> § 9 Cotn Ilaltoe- <br /> O O �n�� <br /> PRC§42956-Registration/Decal in Vehicle - -. --. <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i p ` 2 <br /> Q <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID(dumber from CIWMB <br /> OW <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Re4 Ofs <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ��s <br /> iQ Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsiT <br /> O O . <br /> Other: § �����' <br /> Comments 5 I' l lSe-J "F 1'I t s 4V <br /> -t'j->✓� �-t r a r e� a�L.X a t- -f r wc. , f.J�S 4-e- -A'-el s ct;,-f, ?.,q c-4 `T Ct 4 a <br /> Na v(n <br /> Ilnspection Form Included: 0 <br /> Comments included: Q / � - ��9 `� <br /> Business Rep's Slgn a hone Number ns ctor's Sign re Phone Number <br /> INSTRUCTIONS ON BACK [qonv9Li#-_1no_0 El AMP E 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />