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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r <br /> State nrCaltrre 1 1 - 1 0 1 0 8 1 6 <br /> CflNMB 191(New 04/04) Survey Form - Page 1 <br /> California Integrated Warta Managemaru board <br /> Part A-Survey_ <br /> Inspection Details BLUE OR BLACK INK_PEN_ <br /> Business Iii <br /> TPID- �/ / - O I Ins ection Type — - — -- - - i <br /> t: � P ype (Fill one) <br /> Site Suftb <br /> - 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _ <br /> Business or Facility Name _B <br /> Inspected Ins <br /> P Y Inspector <br /> Physical Address / StI4 <br /> 95�Z Inspection Date 7 O / Q 7 <br /> `F Time In / Time Out <br /> Business Rep Title 0 AM O AM <br /> 0 PM 0 PM <br /> ."' -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whofe/PTE) [^� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r J 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 Q Closed Q Altered <br /> Q Hauler Q indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer 0 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 951-Waste Tire Hauler Registration and Transport of Tires <br /> 007 Q 953-Contracts with Registered Waste Tire Haulers. <br /> Q0 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 /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments iibZ d�iY d 4t�d llrf�cGor <br /> 24,R . - <br /> �+' _ a�.tl4 '1 %,iY ,� /'•wove w >�%y. 1777' <br /> - Z ,l/ �. <br /> --- <br /> Inspection Form Included:Q. <br /> Comments Included:Q <br /> _—, — usines9 R ignaturo -Phot e Number Inspectoes;Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK z }� R tM PL E111213162031 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0723504.0119 <br />