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i Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B ICaliforniatewi Survey Form - Page 1 1 4 10 2 5 7 4 2 <br /> CIWMB 191 New 04104 ■ <br /> callfornia Integrated Waste Management Board <br /> Part A- Survey _ _ BLUE OR BLACK_ INK PEN <br /> Business Profile ,inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: D Z-i d 10 Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name _- — <br /> _ Inspected By Inspector <br /> Physical #ddress <br /> Inspection Date D I 2 I a <br /> 75 <br /> Time In Time Out <br /> Business Re Title O AM O AM <br /> 4+^�w�,�/ C�-glnr 1'<. YvLGt.v�dt�C' -• --- 0 PM 0 PM <br /> Y — V Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> - Active 0 Passenger to Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - O End-Use Q Container <br /> O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler O Agriculture 0 Shredder Q Other �y <br /> Part B- Inspection of Waste Tire Deafer, Generator, Hauler and End-Use Facility <br /> ! '�<; <br /> .•,- - , .01 ,, .,.R "Pow /�" ��' ri/ <br /> L-�.✓/y/'f%`/ / %�`_,%fir:, <br /> 0 I 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle y/ ''" ��✓// �'' <br /> O O <br /> 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 /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 daysy <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 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 H %� <br /> ly <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators /- <br /> 0 0 Other: § <br /> Comments <br /> A/ <br /> Inspection Form Included: 0 'O .��f�j <br /> Comments Included: Q — — - - - —r �-3 76,� — <br /> usiness Re s Sign tore one Number r' a Phone Number <br /> 62081 — -- <br /> INSTRUCTIONS ON BACK '�` Fg 'l�l PW <br /> „� <br /> Waite Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />