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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StateofCaBtornla Survey Form - Page 1 { 9 - 1 013586 <br /> CIWMB 181(New OU8l) <br /> Callfomia Integrated Waete Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � , f � O � Inspection Type (Fill one) <br /> Site Suffix: l•� 4 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local (� H Referral,choose referral type(Fill one) <br /> Identifier: Sai- JO 4- C Q CHP Q CIWMB Q Complaint ®Educational Visit Q Other <br /> Business or Facility Name /1 <br /> Inspected By Inspector <br /> NA'Ma'r' PlQ �eV'J i ca <br /> Physical Address 3 g - 6 I � - Z- <br /> U5 W . kl o <br /> I__7"5 3 3 0 Inspection Date p / <br /> Time In Time Out <br /> Business Rep Title r I 1 OAM Q AM <br /> �n D•fl� �ICIZ �W('�LV� O PM Q PM <br /> v — -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (FlIf all that appy) (Fill all that appy) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Closed Q Altered <br /> GPS Latitude S Hauler Q Indoor <br /> O •Inactive S Truck <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 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 /I/� <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder ®Other r'lam -�r���e P <br /> vktr H5}Lrru� <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 i 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 10 Other: § �,J_ ,,y l <br /> Comments ViSi t 'Ute. ul I QC'f j� ,eMS1 of '<Ah30111 c6wlfy EN b .ff ls� <br /> Pamnf y._ riot re l Rrect -S s ?D lrrz n� digc d a.1 <br /> tell 1hf6rMa n �t'lAJs�(e _L� C�flon CZI.S'h'� ed. �Wyte✓ mag �4iS r <br /> Inspection Form Included:Q /� f rn <br /> Comments Included:Q 3cl& ��� -Business Rep'a.Signature Phone Number_ ap.req.'�s ure Phone Number <br /> INSTRUCTIONS ON BACK I EIXIAIMIFILIE 13 <br /> 62081 <br /> i 01 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0622104.0003 <br />