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Waste Tire Sur. �y & Inspection Report Tln1spection Report Number <br />State B California Survey �p Form Page 1 1 1 1127518 <br />CIWMB tflt (New nage V fey <br />California Integrated Waste Management Board <br />Part A - Survey- BLUE OR BLACK INK PEN <br />Business Profile 1 Inspection Details <br />TPID -' () _ Q I Inspection Type (Fill one) <br />Site Suffix: `� ® Routine Q Re -inspection Q Referral O Observation <br />Local e— Coi If Referral, choose referral type (Fill one) <br />Identifier: Sa 0 J Oct It'l f\ W w T L{ � Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br />Business or Facility Name 1 Inspected By <br />P , S� P <br />Physical AddressLaS ill- <br />u\ <br />Business Rep <br />m)nf) Na <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />cR i5aH0 Inspection Date 1 <br />Title <br />0 corer <br />,au <br />O <br />5O <br />a <br />Operational Status <br />-- <br />Tire Type <br />(Fill one only) <br />O <br />® Active <br />O Passenger <br />Q Closed <br />O <br />Inspector <br />0 1 &(1 CsCha <br />Time In <br />O <br />5O <br />IOAM <br />PM <br />Operational Status <br />-- <br />Tire Type <br />(Fill one only) <br />(Fill all that apply) <br />® Active <br />O Passenger <br />Q Closed <br />O Altered <br />O Inactive Q Truck <br />Q Planned Q OTR <br />I % / 0 f <br />Time Out <br />0 A <br />PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator ® Outdoor <br />Q Hauler 10 Indoor <br />Q End -Use <br />Q New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler <br />Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber <br />Q Service Station O Hauler O Agriculture Q Shredder O Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0,0 <br />Other: § <br />Comments6 ; 1 <br />ir <br />e Container <br />Q Tire Derived Fuel <br />1 » n cry - <br />N = 1. �Q Ci ltJLS1`Ll�.1. (11G �,. 1 t Ic,S ��21 !- �ol, S�r UV ► Lt1,- 4l <br />Inspection Form Included: <br />Comments Included: Q <br />Q - - ----- �"D -&ispec�r's <br />Business Rep's ign�{dT� Phone Number ISignature Phone Number <br />aFEW <br />-- — --- — -------- 62081 <br />INSTRUCTIONS ON BACK �a C I h -P L E1 2 3 <br />White Copy: CI Yellow Copy: Operator Pink Copy: LEA <br />