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�= Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Slate of Callfo—a <br /> CIWMB1 Odg <br /> Clifornia 104) <br /> Survey Form - Page 1 1 6 - 1 0 0 6 4 6 6 <br /> aInlegratad Was-teWMManagement Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 / Inspection Type (Fill one) <br /> Site Suffix: J ✓ ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local e�.,f If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> / 9,55-5- /Ij ���7 �� - — <br /> / Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) O <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill sit that apply) <br /> 6 Active Q Passenger •Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair to 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facilityv.3 <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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days s <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 <br /> ,c <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a = <br /> O 1 Q <br /> Other: § f _ - '-'"�`+u�• [' <br /> Comments / (� sl�►wsi b �n(S t �it �! \wv k- TtYi irro �r�- -- <br /> 51 ICTL _34-51k7Z9 A l h )/c,r?� ' <br /> __1P r,C> 1 a>Z.6 4-2--- 5�=1� Ing o <br /> u -ft o.. CA ttC <br /> Inspection Form.Included:Q G G S <br /> Comments Included:Q - <br /> usiness Rep's Signature Phone Numberoe Sig ature Phone Number <br /> INSTRUCTIONS ON BACK � fi r ' �� i:. I1, ISA P L E Y 3 62081 <br /> �� ■■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0705904.0346 <br />