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u Waste Tire Survey & Inspection Report Inspection Report Number <br /> SWMB Caleomla Survey Form - Page 1 1 7 - 1 0 1 0 805 <br /> Cgrate 167(New qe <br /> Ce6lomie tmegratad Weste IAaneQemenl Bab <br /> Part A BLUE OR BLACK INK PEN <br /> Businees Profile — - Inspection Details <br /> 1 TPID- Inspection <br /> u - Inspection Type (Fill one) <br /> Site Suffix: 7 O 9 Routine Q Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> e 3 �, _ a , <br /> Physical Address <br /> 701 <br /> o v 95330 Inspection Date 9 S ✓ v7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> G'Iy' .P.I't Ds, �llsi O PM O 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 /> ! ! 0 Active Q Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Trude <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair !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 Q Hauler Q Agriculture Q Shredder Q 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 /> Q Q Other: § r <br /> Comments i c.J' clGty au--z' <br /> Inspection Form Included.Q <br /> Comments Included:Qi - - - <br /> s9s-6ySl �' u. <br /> Bus R ignature Phone Number Inspedlx a Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 1112131 <br /> 62081 <br /> . 0716504.0037 White Copy.CIWMB Yellow Copy:Operator Pink Copy.LFA ® ■ <br />