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�zr Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClWM fCaOfomia Survey Form - Page 1 15 - 1025660 <br /> CIMIMe 181 sN Manag) - <br /> Callfomla Yitegwtetl Waste ManagemerH eoard — - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile, Inspection Details <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix: I ; j 3 �- 3. 0 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �^ If Referral,choose referral type(Fill one} <br /> Identifier. � Ohl I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacliityName <br /> Inspected By Inspector <br /> Cly <br /> Physl IrAdddress (.1te,s�rT��1f9h <br /> 3_ l <br /> Inspection Date 1 O S <br /> �J �t..► C/Q 521 S <br /> Time In Time Out <br /> Business Rep / Title Q AM 0 AM <br /> <�1!IltOr� 0 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f <br /> Z � ®Active Q Passenger ®Generator. 1h Outdoor <br /> O Q Closed Q Altered <br /> GPS latitude Q Hauler .Q Indoor <br /> O Q Inactive ®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 ®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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 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. <br /> Comments �cy ! I r�2� I/1��rX�P�S t 1►' q �[� ^7-1r��—r �Y-�� <br /> Q. AST <br /> - <br /> J { <br /> Inspection Form Included:0 1?*3-3V 5 <br /> Comments Included:Q - <br /> Business Reps igna ure Phone Number Insp ors Signator_ Phone Number <br /> INSTRUCTIONS ON BACK FE14AIMIPILIEt 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0525804.2008 <br />