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rs== Waste Tire Survey & Inspection Report Inspection Report Number <br /> i!3 State of California <br /> CWMB 1 teMana 4) Survey Form - Page 1 19 - 1 0 0 6 1 0 6 <br /> - California Integrated Waste Management Board <br /> PartA-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral ®Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifler: � ( — Q CHP Q CIWMB O Complaint .Q Educational Visit Q Other <br /> Business or Facility Name v� Inspected B <br /> p Y Inspector <br /> Physical Address r <br /> l � t7 <br /> to <br /> Inspection Date <br /> Seo LA-_ � �®(0 <br /> Time In Time Out <br /> j Business Rep Title 1 Q AM Q AM <br /> ® PM PM <br /> 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS <br /> Q Hauler Q indoor <br /> O 9 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 O Crumb Rubber I <br /> p Service Station Q Hauler Q Agriculture Q Shredder ® Other Wcytiyt,Ot�yL <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ¢ 3 <br /> OR <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 z n' <br /> , 4 <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 00. <br /> s :, <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers x h <br /> Q Q 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilitiesr <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q .Other: <br /> Comments <br /> Cow c c_C.��— �'.t�_ -c.c_► ��r-c,�n,c <br /> 5 ow ctg v <br /> t <br /> vwc_ ► �G �-ti f) ow� Gt/�, Elf d <br /> Inspection Form Included: <br /> �?Comments Included: Q . <br /> business Rep's Signature Phone Number Ins actor's Signa ure: ,... Phone Number. <br /> INSTRUCTIONS ON BACK f 62os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0 5_29-0 4. 1 16 <br />