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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWMfCalifornia survey Form - Page 1 i 1 0 4 8 9 4 <br /> CIWMB 18181jN(New 04104) ., <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PE_N <br /> Business Profile_ 'Inspection Details <br /> TPiD- Inspection Type (Fill one) <br /> Site Suffix: 1 ci 6 SRoutine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local ,-�ti 'If Referral,choose referral type(Fill one) <br /> Identifier: � I O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName � w � Inspected By Inspector <br /> Ph�isical <br /> /"J'hv2-� <br /> Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM a� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) © (Fill one only) (Fill all that apply) (Fill all that apply) ! (Fill all that apply) <br /> f Q Active 0 Passenger Q Generator Q Outdoor <br /> 0 t0 Closed I O Altered <br /> GPS Latitude Q Inactive I O Hauler O Indoor <br /> 0 <br /> 0 Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair *Trucking Fleet Q Government Q Retreader Q Dismantler O 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 4@ Otherri <br /> Part B- Inspection of Waste Tire Dealer Generator, Hauler and End-Use Facility ENFQRCEMI^NT6TAT�!$ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> �3s <br /> Q Nattce Of V(a(atlan f <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires x7", �;. <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. .vy .... <br /> Q O § 9 Complianc4 gtuildllns <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements j Date / <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 1 O 1 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requtfe fp1 NQVAf y,, <br /> 9. <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> OO 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 0 Other: § s t5 i .,._ yr '•: <br /> Comments <br /> D,- Z.a�•!, w <br /> 1, �Cl�trfr�ut - .Q- �'r"�e. !/�S�' . -'Jo.rb► ` Tf7n�K.S 1ivh+�G Da <br /> 5 <br /> per 1 i �Ca rdrac.tc�r. 41 a. ..2,r 6y p oto . <br /> `Trr�ks `+►,� "�"ialc� —}v -->F'A�e. s^� S -Cb r -rvicAit / <br /> Inspection Form Included:O <br /> Comments Included:Q $ <br /> 1 Business Rep's Signature Phone Number Insp r s SI Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK COi�rac#; Mc.�mect:_ �V� E X >fi M P L E f 3 <br /> ■ _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.L1:,4 <br />