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�i Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Cahfomla <br /> 181(NastewWle<) <br /> CSurvey Form - Page 1 f 3-- 1 01 3 6 3 0 <br /> alHomte Integrated Waab Manaasmant 8_dPart A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile _ _ Inspection Details <br /> TPID- / / - t✓ Inspection Type (Fill one) <br /> Site Suffix: 0Routine QRe-inspection <br /> Q Referral Q Observation <br /> Local `/�, If Referral,choose referral type(Fill one) <br /> Identifier. QCHP Q <br /> CIWMB <br /> Q Complaint Q Educational Visit Q Other <br /> BusinVyName � 2'iilInsPe-ted By Inspector <br /> Physical Address <br /> L�Z -rte 9S'33 Inspection Date 6 s Q / <br /> Time In Time Out !7 <br /> Business Rep Title �� 0 AM 0 AM <br /> /v� ja e, <br /> �r4 O PM ( ! O PM <br /> Operational Status Tire Type Business RolT torage Type <br /> Tire Count(WholelPTE) (Fill one only) (Fill all that apply) (Fill all that appiA all that apply) <br /> Active Passen erQ g •GeneratorQ Outdoor <br /> O Q Closed Q Altered ,(/ <br /> GPS Latitude Q Hauler Q Indoor Z— <br /> O Q Inactive �Truck <br /> Longitude – Q Planned Q OTR OE Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment (Di Retread-or Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> LOServicef,,, +4/Station Q Hauler Q Agriculture Q Shredder 40 Other / r�r�,e . <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q 1 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 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 1 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 /> 010 Other. § <br /> Comments 'LLG Q�`Y�r kQ pe�� cj-- jAee 404V-,(C �4�„Af:f j/ r'- <br /> e.' lc.� aze )z^>! <br /> Inspection Form Included:QI <br /> Comments Incfued:Q <br /> dg�, 7 � r_ t `�Oa 0 <br /> Bus as s ure Phone Number Inspecto7a Signature Phone Number <br /> . INSTRUCTIONS ON BA E XAIMI P L E111213162081 <br /> White Copy CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0619404.0052 <br />