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® Waste Tire Survey & Inspection Report Inspection Report NumberState of ■ <br /> ClWMB1a °la Survey Form - Page 1 14 . 1 .0 O fi 7 0 1 <br /> CIWMB 791 t(NawM04) <br /> CalHornla Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> I TPID- Inspection Type (Fill one) <br /> Site Suffix: p 43 - o 1 '®Routine Q Re-inspection Q Referral Q Observation <br /> Local ..� If Referral,choose referral-type(Fill one) <br /> Identifier. <br /> Nh,p cGf j�&K �lJ-�w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physics Address <br /> 3672 c- <br /> � <br /> Inspection Date <br /> 5�c <br /> Time In Time Out <br /> Business Rep Title _ OAM h Q AM <br /> @1PM 4 O U O PM <br /> Operational Status Tire TypeBusiness Role Storage Type" <br /> Tire Count(Mole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator Q 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 Q "14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 1 Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q ' Q 114 CCR§18459.3-Retention of Manifest Fortes 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 /> CommerrtsT((���kC.�- 5 MZ lro Lh <br /> G o tY'.� } ` ►�rti �.,r>1 t t.1 wL w o IV\ Entered <br /> aL U V .w Lc�1cc.-w KS <br /> Inspection Form Included:"Q <br /> Comments Included:Q <br /> Bus! s �,.n�al. ,�.n—e NumbIns t to Spis Signature' Phone Number <br /> INSTRUCTIONS ON BACK P i 12 3 62081 <br /> 1 i <br /> ■ - White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0529204. 1084 <br />