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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ■ lir <br /> fellforn ie <br /> CIWMBWMB 1 Survey Form - Page 1 1 4 - 1 01 3 5 6 5 <br /> 181(New 04104lCalifornia Integrated West.Management Board <br /> Part A-Survey _ _ BLUE OR_BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' O J /_ _ O Inspection Type (Fill one) <br /> Site$UMX: v t(f is Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q Q/�yt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector ` <br /> i S � Su zcc 0 S� <br /> Physical Address1J,�r n--11, S/1�—Mi N)r5,4N!f <br /> 3 j 3 ► t4dr, Ce,%�ter e; Clrti - <br /> Inspection Date © � I I / Q G <br /> h95a1a r <br /> Time in Time Out <br /> Business Rep Title °AM °AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Bualness Role etorape Type <br /> The Count(Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill d Ytat apply) <br /> f *Active 0 Passenger 0 Generator 0 Otltdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude <br /> O 0 Hauler Indoor <br /> Q Inactive Q Truck <br /> I <br /> Longitude — Q Planned Q OTR Q End-Use 0 container <br /> Business Type (Fill all that apply) — --- <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body t♦Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture 0 Shredder 0 Other <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 /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 Q PRC§42956-Regis[rat ionlDecal in Vehicle <br /> Q 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-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 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 /> 0 0 Other § <br /> Comments j�/1 (LOy1 /Vwa daV _p. �D jjnej6Q K)&S Kot4 J, <br /> ei ' has,, 71nar 9 res of a tiM, <br /> VP ` RQZ Wim" <br /> k� <br /> Inspection Form'Included:Owi V comments Incl <br /> B eksignature Phone NWtttter Inspect is Si tura _ Phone Number <br /> INSTRUCTIONS ON JA I E X A int P jL1_ET 111213162081 <br /> ■ Whfte Copy:CIWMB yellow Copy Operator Pink Copy:LEA ® ■ <br /> 06222104.0016 <br />