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Waste Tire Survey & Inspection Report inspection Report Number <br /> ctate of wMs11(Now Survey Form - Page 7 I $ - 0 2 5 $ 2 9 <br /> CIWMa t81(stew 04104) <br /> California Integrated waste Management Board <br /> Part A-Survey_ _ _ _ _ _ _ _- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -BLUE OR BLACK INK PEN <br /> 1 slness Profile — _ _ _ —_ _ - Inspectlon Details - <br /> I TPID. \ 6 inspection Type (Fitt one) <br /> Site Suffix: Q Routine ® Re inspection Q Referral Q Observation <br /> i Local I If Referral,choose referral type(Fill one) <br /> fIdentifier: +O CHP Q CiWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> i Inspected By inspector <br /> Phy cal Address ` - l �V rJ�W ` Crorm - <br /> I <br /> 3 OOC inspection Date <br /> ! lJa <br /> 111 1 Time In Time Out <br /> Business Rep Titie I 0 AM 0 AM <br /> Vv. O PM - -O PM <br /> operational Status I Tire Type j Business Role Storage Type +!! <br /> Tire Count(Whole/PTE) r ' ,. - (Fill one only) I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ° 10 Active 0)Passenger a Generator Q Outdoor <br /> 0 1 Q Closed Q Altered <br /> GPS Latitude I i I Q Hauler I Q Indoor i <br /> p Q Inactive I Truck + 1 <br /> Longitude - I Q Planned Q OTR ± Q End-Use I -Q Container1 <br /> - - - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O 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 ®Other 1e � <br /> I <br /> Part 8 inspection of Waste Tire Dealer,Generator, Hauler and End Use Facility i' " Y" <br /> �j �r t��r �1 , - s i e.- "✓,S"i -3as..�1' '' s -mak ��`�`�� -^�s <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires )�37�i� s' <br /> Q + Q I PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q I QI PRC§42956-Registration/Decal in Vehicle <br /> Q i Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements %? <br /> Q I Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> I Q Q 14 CCR§ 1845921 -Submittal of Manifest Forms and Tire Trip Logs wthin 90 days <br /> Q Q � •-��ft'/%'�"%�,�i^��y��i/f,✓,/y,am/'����`s,- <br /> 14 CCR§18459.3-Retention of ManifestForms and The Trip Logs for 3 years NMI <br /> Q Q 14 CCR§18460,2-Manifest System Requirements for Registered Waste Tire Haulers <br /> j ✓� � ,g' ' " <br /> Q Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilitiesiy �3 s <br /> �,. <br /> Q 1 O 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q I Q !Other: § % <br /> Comments I -L&A-7 (4- T�nolr <br /> A <br /> t 1✓�i"��l 1.v.N -- �S M�i o <br /> r.w tc-,U- <br /> Ilnspection Form included: Q <br /> Comments included: Q - <br /> Business Re ' Signature Phone Number In tors S ature Phone Number <br /> 62D81 <br /> INSTRUCTIONS ON BACK 'y � �r� Iy' A`tMi F L E Y 2 3 <br /> Entered White Copy.CIWr,na Yellow Copy:Operator Pink Copy:LEA <br />