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Waste Tire Survey & Inspection Report Inspection.Report Number <br /> snIAB181(N.* Survey Form Page 1 1 3 101 3 7 3 8 <br /> cg.t fatst.r o g0 Y ,. <br /> CaNfomle Integrated West.Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- 3 1 5 / Inspection Type (Fill one) — <br /> Site Sufflx: 3 y 3 _ Routine Q Re-inspection O Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L/ U <br /> A4c(.rJt u n �nv� (� <br /> Inspected BY /� Inspector <br /> Physical Address V'v 3 "I - ! C) / je;t_,tigt�� <br /> C4- 7�75��` Inspection Date <br /> �L6// Time In Time Out <br /> Business Rep + l Title + 0 0 AM ' U O AM <br /> 13ry I'1e a� Vv����Q� irViCf G&di 1`_ 0 PM Q PM <br /> 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 /> r r (`/ ®Active Passenger o Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude - Q Hauler 0 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 O Agriculture OS hiredder •Other I"'aww6auKeJ 1 bme <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q 'PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <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 <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18458.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q I Q Other: § <br /> Comments Jk5 t:k0l,\ -RUS CD OW! was no <br /> _ frztnsport"mgLu. hom, iP- _717ajev-s ar,e <br /> &sa.ssgi,Kbled aAd Jb-n are r owled bW B6t'Ente,- r see i n wocid(anon_ <br /> CTO; i <br /> uceK/ a Tt es-_a - u 5 - c% a.�.L i.s �Jo v i olall 043, <br /> Inspection Form Included:Q 3q-87a n � � <br /> Comments Included:Q <br /> Busi ss Ra 'e SI nature Phone Number In s Phone Number <br /> INSTRUCTIONS ON BACK ® �IIX R M P.L 1 213 .62081 <br /> ■ - White Copy.CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br />