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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 5tWMB1at ail(New Survey Form - Page 1 i t - 1 0 0 7 9 6 <br /> CIWMB 187(New Od10d) <br /> Callfomia 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: lL <br /> ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� Q _� � � — If Referral,choose referral type(Fill one) <br /> Identifier: s L 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V — <br /> Inspected BY Inspector <br /> ct <br /> 7 lz���I� ✓'i 3 C <br /> Physical Address <br /> S%((J1('}, )�� Inspection Date O D 9 / 6 <br /> �-- Time In <br /> Business Rep Title 0 AM Time Out 0 AM <br /> DcthAA <br /> /�I tec4rtiC�a4I 0 P 0 P <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(W hole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> O ` Inactive 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 Govemment 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 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 <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 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 /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ' <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years u k ~ y ' Y <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 i 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 1 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 O 1 Other: § <br /> Comments U7 7 L%ttj^( CS achw1 <br /> tvil, Q�t vj i*?6 daiaka. inset l ren l T 4 f ob 3o.- 1;5ied as <br /> lnacVk. t wntr aloes o+ 5d or use Or a;& wta.ce `M-e S. <br /> _J�ar�('�-r✓ems `t'i�l�-� <br /> Inspection Form Included:0 - n <br /> Comments Included:0 - r 3-05� q4?80 <br /> Business R s Signature Phone Number I or'$. gnature Phone Number <br /> ■ INSTRUCTIONS ON BACK � i E _ AMPLE 1 2 3 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® r <br /> 0719304.0031 <br />