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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CFWM taa0lar°`' Survey Form - Page 1 1 2 - 1 01 3 6 7 <br /> aONMB 787(Naw nage <br /> Callfomla integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ,j ' 7 p / Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf 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� Inspected By Inspector <br /> aS 17u'r`n A//P'G7(;A,A <br /> Physical Address 3 9 o su Et aarw A,-. <br /> ,5-1 -97 <br /> Inspection Date p J / O .2, 0 7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all Owl apply) <br /> r r 0 Active Passenger 0 Generator 9 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that appy) <br /> Q New Tire beater 0 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 <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§16459 -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 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tre End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § ,/- / s <br /> Comments Ami G) A-..s/`�hQ _1" IGC�C.�+✓C LL��+y� <br /> of ZW 4-,f I<.'-o--e . X;2.-&i'�K /-P <br /> Inspection Form Included:/Qc � <br /> Comments Included:QRRep's Signature <br /> key:fef.r� >��. ---_ lfr/*-,�71 a"��-- ��.•+n.C�gs��.eI7.' <br /> _. <br /> Business <br /> � <br /> Signature Phone Number Inspector's_Signature Phone Number <br /> INSTRUCTIONS ON BACK ! FETxTAF_ FP1L1E1 1112131 <br /> 62081. <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0705904.0324 <br />