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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CiWMB 18aNewi <br /> afCaliforniaSurvey Form - Page 1 1 2 - 1 01 4 71 0 <br /> WMe <br /> California Integrated Waste Management Board <br /> Part A- Survey— __ _ _ _ _ _ _ _ _ BLUE OR BLACK_INK PEN <br /> �uslness Profile inspection Details _ _ _ <br /> -r - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z �� f7 �� 3 1 I;It 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 - - --- -- - -- - _ - - - _ - <br /> Inspected By Inspector <br /> 6l � ro�w� �iC­(-� <br /> Physical Address 0 <br /> q Inspection Date 3 p <br /> Time In Time Out <br /> Business Rep ��7 pq JQ� Title ,�,,�,��,, // O AM O AM <br /> V A4V�OV1 VAN' U'n" �. - - --O PM O PM <br /> — --- — -- - -- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (W hole/PTE) 1(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator Outdoor <br /> GP$ Latitude <br /> 0 Q Closed Q Altered o <br /> Q Hauler Q Indoor <br /> C Q Inactive ®Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® 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 / /f <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O f O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days y <br /> Q Q 14 CCR§18459,3-Retention of Manifest Forms and Tire Trip Logs for 3 years / <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers s <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 010 Other: § <br /> Comments - T <br /> �5—_ ld Lei - 5 lY — �vUtS_ S nSt - <br /> was�'� <br /> Inspection Form Included: ® _ <br /> Comments Included: Q �yr �--/�Jn_�p'� <br /> L - _ - siness ep's Signature Phone Number Inspect is Signature _ Phone Number , <br /> i y-. r "- ✓i. .;.� %, - - - 62081 <br /> INSTRUCTIONS ON BACK 7C A%Ny p L E( 3 <br /> o <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />