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s Waste Tire Survey & Inspection Report inspection Report NumberStaw of ■ <br /> CWMB`et(er"� Survey Form - Page 1 I l - 9 01 3 1 3 9 <br /> CM/M81Bt(New raga <br /> California tdegrated Waste taanaeament Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details -� <br /> TPID- /' Inspection Type (Fill one) <br /> Site Suffix: 7 6 O S 3 - O <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local n / H Referral,choose referral type(Fill one) <br /> Identifier: J S�sK p`�4q �� y� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> a <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> 936- <br /> h <br /> ysical Address <br /> �/ Inspection Date <br /> fp (�f� Time in Time Out <br /> Business Rep Title/7 D D •AM Q AM <br /> G/ //awl amt S Y/ Q PM Q PM <br /> - Operational Status Tire Type I Business Role i Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> A Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 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 Q 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 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility t•. <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 Dats O)) <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 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 r <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § y <br /> Comments ���•�- / Caw <br /> =_�/ <br /> �+OSP21 an� c�u�le lis �✓ <br /> l!/ V ✓'v7 c?a'e /�as�e.� lly�Yn... 9�e �'.o' Gcft -,t <br /> Inspection FormIncluded:Q <br /> Comments Included:QA - <br /> Bual s Rep's Signature Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK jEjXjAjAkjP1L1Ej 1112131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 0703804.0464 <br />