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Waste Tire Survey & Inspection Report Inspection Report Number <br /> StateSurvey Form - Page 1 1 3 - 10 2 5 79 0 <br /> New <br /> CIWMBB118101(Now <br /> (Now 04104) <br /> Celifornla Integrated Waste Management Board <br /> Part A-,Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- � � � � � � _ � Inspection Type (Fill one) <br /> Site Suffix: o Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �6h t � �i��t✓r�y � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ inspected By Inspector <br /> I Phy kicalddress <br /> )z,#v �j A <br /> Inspection Date O f <br /> Gh Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 Z4 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O ® Active ® Passenger ® Generator Q Outdoor <br /> Latitude C Q Closed Q Altered <br /> GPS Q Hauler 0 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 EN N'f TATUS,:��___._^ <br /> k HA it ANb IIMAIOFM T' PX <br /> R N1F..i�tTB . n <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �.! CivilQztandon <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I I <br /> Q Q PRC§42956-Registration/Decal in Vehicle ` m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB { I I <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days d lyQV ar <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years 1 <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Other: § <br /> Comments "va4el- ),.,` �15r i r <br /> `�G>!,l,✓c, � G lSr� ���, (ts -�-;r-� �sJrctS -� �j�v.— �r� <br /> ln�L.9 s �t �i+`'�x � t'}/� C�r•5l'�� I^ 't'�IL G%Si <br /> Inspection Form Included; �t/'I, f �� <br /> Comments Included: Q lµ•�J'�,/ <br /> Business Rep's Signature hone Number Ins or's ignatur Phone Number <br /> INSTRUCTIONS ON BACK j �a>: �'lI,h1P L�_�� _ 131 62081 <br /> Entered White CopyCIWMB Yellow Copy:Operator Pink Copy:LEA <br /> KB <br />