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t Waste Tire Survey & Inspection Report r Inspection Report Number <br /> State of Survey Form Page 1 C 4 - 0 0 8 D 1 Z <br /> CIWMB181181(Now 04104) <br /> Callfornla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Dotalls <br /> TPID- ^-7 Inspection Type (Fill one) <br /> Site Suffix: ` a 3 b ,Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q`�,� • Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> /I� 11 inspected By Inspector <br /> Physical AVess <br /> �>O 703 <br /> Inspection Date 0 / <br /> _-.cGy <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ,�j � <br /> Is Active Passenger 0 Generator Q Outdoor <br /> Latitude <br /> 0 Q Closed �Altered <br /> GPS Q Hauler Q Indoor <br /> O Q inactive Truck <br /> Longitude .. Q Planned OTR O End-Use 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 •Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use FacilityNF`a )�' T <br /> - - - <br /> V,; Ai HAULING-AND-MA FEST�REQUIREMENT8 ' <br /> Q Q !PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q_hI6tI0r 1i'llpt#j�OftSF # Ij <br /> Q Q 'PRC§42953-Contracts with Registered Waste Tire Haulers. GAmpll#r�telil�i4i+� �' it <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements <br /> Q Q 74 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 _161 <br /> fy s> sir '5M <br /> O O 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> § P 9 Y ve.irk . <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers > k, <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End Use Facilities ;�i <br /> O O � <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r� j moi:gy <br /> 01 Q Other: § <br /> � <br /> Comments 5;trlrVQa/ 1's ¢.. \VV_ � �.GISVIb� , <br /> �e�,�`�r <br /> C_ aN�r-JS _C-vV% 1� s�res ti`�a-- -I1e— <br /> kn rt_ts <br /> Inspection Form Included: Q <br /> Comments Included:Q �` � -- �5 7162'16 <br /> (Business Rep's Signature Phone Number I fje f n Phone Number <br /> INSTRUCTIONS ON BACK CQr ;�nrcrot } }L" P L 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />