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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMa1 asteManage Survey Form - Page 1 1 3 - 1 0 0 6 7 6 8 <br /> Callfomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile . Inspection Details <br /> TPID- r I - O Inspection Type (Fill one) <br /> Site Suffix: j ` - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill on) <br /> Identifier: m 'Tb(�T��j,C Nky& Q CHP Q CIWMB Q Complalnl Q Educational Visit Q Other <br /> Business or Facility-Name- - <br /> / 7^ Inspected By Inpeetor <br /> Physical Address f�i <br /> 1(o to Navi <br /> �� , �, 16�� Inspection Date O % / p� 3 / C <br /> /'+t�`\..i�-l�J Time In Time Out <br /> Business Rep Title tJ t✓ 7 O PM O O PM <br /> R' � I DWr�ev Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) +1 t fillO (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O( 0 Active 0 Passenger ®Generator 0Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fin all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Relreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber AA�� /� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other /"Fo�?l 1e I lte &rV lcw <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 IQ 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§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 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 /> Comments_.!1Q►ti14n.t?i. !J1� 2G d.Q_`i'h!s . ak'o_ `1 ke_ __11aA)Uiujgas Al o <br /> Facilifv vsys F i ir-e -h rtmit, Airts orice <br /> hllan` 6-e, Oew A. Mtoed Fires Ar 0_,k 4. Aw6k fjriesil, mgM fires <br /> No 'o _+i_onS, WNV aa'4 WAOCT-im fihii disVi 6d?i <br /> Inspection Form Included:Q <br /> Comments Included:QI Business Rep's Signs ure Phone Number ctor nat <br /> gure � Phone umber <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK E X Ilk1PILIE1 1112131 © ■ <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />