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Waste Tire Survey & Inspection Report <br /> rrc. Inspection Report Number <br /> rr <br /> State of California Survey Form - Page 1 1 3 - 0 3 1 4 3 <br /> clwree tst(N..anal <br /> CalMornla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 g y / D Inspection Type (Fill one) <br /> Site Suffix: f J Routine <br /> ® Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: J« Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected Inspector <br /> Physical Address 3 9 – / •(/ S uQ Gs� ffjj�Cy�� <br /> Inspection Date ,Z ( / CIO,, <br /> r Time In Time Out <br /> Business Rep Title Q AM O AM <br /> O PM O PM <br /> -- ---— - Operational Statue Tiro Typs Business Role7(FFll <br /> e Type <br /> Tire Count(Whole/PTE) p� (Fill one only) (Fill all that apply) (Fill all that applythat apply) <br /> r r �" 0 Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> D Q Inactive Q 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 0 Trucking Fleet Q Government O Railroader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility l=tlfit ' <br /> 7000007pi <br /> §42951-Waste Tire Hauler Registratlon and Transport of Tires NotIS F)P 9/io§42953-Contracts with Registered Waste Tire Haulers.§42956-RegistratioNDecal in Vehicle <br /> O O �14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities x <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other. § .._. . <br /> Comments te�14>. <br /> sG7e �j/'x# <br /> �a tz>«.C.,�1�-f �Gl.: err ar! ���o Gv vt� �� t7'�.c 3X� <br /> Inspection Form Included:10 <br /> Comments Included:Q <br /> -.4— Z e <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number_ <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 111213 62081 <br /> ■ White Copy.CIWMB Yellow Copy.operator Pink Copy:LEA ® ■ <br /> 6703804.0443 <br />