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1� Waste Tire Survey & Inspection Report Inspection Report Number <br /> CWMB1 <br /> State of Survey Form - Page 1 i - 1 0 0 8 0 3 <br /> C g r 81(New 04104) <br /> California Integrated <br /> 1d Waate Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ _ Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 6 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 orFacilityName _f� Inspected By Inspector ' <br /> Physical A`dGt a O� i '�.r�t-bv� f Q / / �ry�f ►tel` [:I��ttS <br /> 326 r /-��,-�, i%�.�r-��.- G�►�Q 1...�-' <br /> SZ) Inspection Date d <br /> Time In Time Out 1 <br /> Business Rep((}} p Title OAM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) c7 j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active @ Passenger ® Generator Q Outdoor <br /> ° Q Closed Q Altered <br /> GPS Latitude <br /> O Q Inactive Q Truck Q Hauler Q Indoor <br /> Longitude - Q Planned Q OTR O 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 t'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 ENFO1t I <br /> . 1 <br /> V_ A HAULING AN.D_MA IFRt8T REAIJIREMENTS Q ttQtic�£tf��f l b l It <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires , v � <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Ctrlrtplll�i6tj <br /> O Ot- ✓ x>x ?;tis{y <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pig <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program W Number from CIWMB i <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> /`, <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 /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities i, <br /> O I 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 LO ,I <br /> Other: <br /> Comments /{,� .a� �c.,�+r- �4. [�/Z l�4•�Z•J � bv�►r�i-t'Pi��-' S�y }�_ •— )�hs�tt I ira..�...'r-3 <br /> �f®�+�' wv�y�"c,r -�"�1•-e� Cv�ry.� -- � �,.�5►•-��i �!►'� f�r�l �sr <br /> 4v (j!CQ�LWA qSj Z_ -G,- I.,A5pe,4*'q, HL%_ <br /> tom.-�.+�I-wig•'�-S �v.Sii�G 't'�r I r S t� . I o►�C � Ir�t N,i-�i2s�^5 <br /> Inspection Form Included: Q Q� <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number In is Signa a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I --.,_ n , r. . ':�V1.. ?i A P L E 1112 3 <br /> ■ Whit Copy:CIWM Yellow Copy:Operator Pink Copy:LEA <br /> l� <br />