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Waste Tire Survey & Inspection Report Inspection Report Number <br /> r State of California <br /> Cgrated 1steMaage Survey Form - Page 1 1 3 . 1 0 0 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 2 f 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> G ��__��..__ __�,-n J� Inspected 8y Inspector <br /> et'Physical Address l g <br /> D / ���f� Inspection Date D -7 ! I <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O Pin <br /> f� vY-- IG2 j"I�ivctsi <br /> Operational Status Tire Type Business Role ' Storage Type <br /> Tire Count(Whole/PTE) �� .� ~viJ �'�'� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® GeneOutdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 10 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFOR 1~ R-NT.j�rW u m� <br /> V A I HAULING AND MANIFEST REQUIREMENTS �0 Noti1;41 Qi 1/)gl0tldn 0 I�$f�rr�f�ri <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Catllpllarf+�� I;?r J+ lln� <br /> 0 I, 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§ 48459.1 (a)(h)(cj-Tire Program ID Number from CIWM6 ,J <br /> 0 014 CCR§ 18459.2.1 -Submittal of Manifest Forms and lire Trip Logs within 90 days y� <br /> f <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 <br /> 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 y f <br /> i iif i i// <br /> 0 0 14 011 <br /> CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators /��i <br /> 'Other: § `<;i/ ./i�M�� i! <br /> Comments F':�Gt I*y -I/3o <br /> v 105 CA /r ' lT JIC 1 to I� "`" <br /> ^ "t7 e J2� <br /> Je �r�s�' tz1 / iGnf-�cs-� Ca J.�S U -� <br /> ,ikw- <br /> Inspection Form Included: 0 _ (711 <br /> Comments Included: 0 <br /> Busine P's Signature Phone Number tor's nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC LC eCt._ ( trref3t� R PrL E <br /> White Co y;CIWM Yellow Copy:Operator Pink Copy SEA <br />