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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 5t.t°°t`al(New Survey Form - Page 1 I $ - 1 01 3 6 9 <br /> CIWMB 161 t.M..g <br /> California Intsyrand Waste Managanrnt Board <br /> Part A-Survey__ BLUE OR BLACK INK PEN <br /> Business Profile insp�etiort Details <br /> TPID- 1 3 S 6 ! - D / Inspection Type (Fill one) <br /> Site Suffix: / C 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> local _� //,Ii �! If Referral,choose referral type(Fill one) <br /> klsntfflar: �QM �T�Q l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name A <br /> Inspected By Inspector <br /> Physical Address 9 / Q/3fll /f`'t'y <br /> Inspection Date 0 S 301 O <br /> G>9 9s330 <br /> Time In Time Out <br /> Business Rep Title / / Q AM (� Q AM <br /> l� CSS ��H �tiLGM•CRst C a PM ( / 0 PM <br /> Operational Status Tire Type Business Rok .Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 <br /> Active 0 Passenger j ®Generator .Q Outdoor,/ <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 0 <br /> Inactive Truck <br /> Longitude _ 0 Planned 0 OTR o End-Use 0 Container <br /> auslnessType (04 oil that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Relreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 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 1 Q Other: § <br /> Comments <br /> 7-PI® <br /> Inspection Form Included:0 <br /> Comments included: *1 <br /> -- -Oug <br /> /�� -- r •G � �aj 3� <br /> Business Re 's Sig ��vn-s re hone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 111213162081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br /> 0617904.0101 <br />