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r Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIStottB CalNaml. Survey Form - Page 1 1 4 - 1 0 1 3 6 15 <br /> CIWMa 191 stew nage <br /> cynoml8lna9r.rb w..e.M.�.s.m.��eo,m BLUE OR BLACK INK_PEN <br /> N <br /> Part A-Survey - Inspection Details <br /> i Business Profile p <br /> TPID- / � � � � � � 'Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: —?aj2 VOCE- Q CHP O CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �/4-,'7�G.��4 <br /> Physical Address a 3 / / / 016, 7'VJ*-0t'¢ <br /> P / 41,s 7 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 10 AMO AM <br /> I <br /> : ys / : � s�O PM O PM <br /> — O stional Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container J <br /> Bualness Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 41 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 1 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 : 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 00 Other: § <br /> Comments <br /> rAP0io-tom <br /> Inspection Form Included:Q � ' c �_ ' � —4,(Z-0 <br /> ' (y o3 <br /> Comments Included:0 Bua a ep'a grurture <br /> kPhon.�u�.ber ' Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK ® X Ai M P .7 E 1 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br /> 0617904.0249 <br />