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�t Waste Tire Survey & Inspection Report Inspection Report Number . <br /> a sista or California 7 �/.�t <br /> CIWMB 191(Now 04104) Survey Form - Page 1 5 - 10 10 1 2 9 <br /> Callfomla kdegrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,L 3 / 2 - / Inspection Type (Fill one) <br /> Site Suffix: "[ 6 3 J ®Routine Q Re-inspection Q Referral Q Observation <br /> Local (�- If Referral,choose referral type(Fill one) <br /> Identifier: �`�(!/LJIV (((✓� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /f� <br /> f Inspected By Inspector <br /> A.}. chc� 6)b <br /> Physical Address <br /> a9oq -i- La, - <br /> S-Ir'7V� I1 t lVL <br /> G /�„ Inspection Date s / ' y / O <br /> O` J Time In Time Out l <br /> Business Rep Title O AM O AM <br /> n i l 10� f/ O PM ---- O PM <br /> Db f�V`w l 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 /> f ! ` IS Active ®Passenger .®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive a Truck <br /> Longitude - Q OTR Q End-Use Q Container <br /> Q Planned <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 I♦Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> p Y .. ,� ,a•`� <br /> Q Ot: <br /> 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 �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 /> a ate, <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 s , <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> .r <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities s ? ' <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r _ <br /> Q 1 Q <br /> Other: § <br /> Comments �{7`,>_„ - !c• � 19{1 �,/' ,, t o/, ko 'CLn•a1- ``(�s <br /> iags �i'`ctrl.N.Dh `7-'�'- w� -AZs <br /> (�C f/ C � / SGS`+s <br /> Aewead e JJo Jiolc_ior,s rwtevL <br /> Inspection Form Include <br /> Comments Incl :Q I ^3 S <br /> u iness Rep's Signature Phone Number_ Ins is Sig re Phone Number <br /> INSTRUCTIONS O ACK p L E 111213 62081 <br /> n i <br /> ■ A 1r,504.011 i White Copy CIWMB Yellow Copy:Operator Pink Copy:LFA, © ■ <br />