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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Slate of California <br /> cIWMBtB,(Now g41U4, Survey Form - Page 1 i 6 - 1 0 0 8 0 3 9 <br /> men <br /> California Integrated Waste Managet Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: - <br /> �j' � � 1 � Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifior: J�4�� ���� Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 13�L 1 r-e f� <br /> Phy Ical Address 3 / �icrr -Vc4C�Lc t S <br /> Inspection pate � � / O (1 <br /> Time In U Time Out <br /> ll <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 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 /> ' f Q Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude lb Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> j <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 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> Y =A I HAULING AND MANIFEST REQUIREMENTS I <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires d,HQtI>+ �f/Oldfirrn (�- Mton8lprl <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C0► l{ aF <br /> Q Q PRC§42956-Registration/Decal in Vehicle '} s'l <br /> Q ! Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§ 1B459.1 (a)(b)(c)-Tire Program 10 Number from CIWMl3 <br /> Q Q i 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days / <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> r4 <br /> Q 0 .14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q r 4r Kr <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities � � <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators J f ,, <br /> Q 10_Other: § F %/'/ /.�`. ;; <br /> Comments L� <br /> r�� —n- -��a--•� c f5�gc= ��-5`'rtCJ1t..� �� - `...-c�v,'f"c'S �-- <br /> Inspection Form Included: — <br /> Comments Included: Q - �Z } -� `-73 <br /> - —2- <br /> Business Rep's SignatuT� Phone Number r' Signature Phone Number <br /> INSTRUCTIONS ON BACK CA`•*]�/}''`` { � R p 2� s2081 <br /> White Copy IWMYellow Copy:Operator Pink Copy:LEA <br /> ® ■ <br />