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z=: Waste .Tire Survey & Inspection Report Inspection Report Number <br />"'i — <br />ii� State B California 11 1088068 <br />Cgrated Waste <br />eManage Survey Form -Page 1 <br />California Integrated Waste Management Board <br />'art A- Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - I � � � / /'� /t'� O � _FoTi(J <br />Inspection Type (Fill one) <br />Site Suffix:�1 ` S Routine 0 Re -inspection 0 Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: CM4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected B <br />P y Inspector <br />Physical Address <br />M3 S E� D ori L 111 �-V jjj V <br />StreetCA <br />Inspection Date <br />State LIP Cofa <br />xV <br />�J Time In Time Out _ <br />City <br />Business Rep Title -��0 AM <br />11 �,Q A PM l fa1 Q AM <br />I 5 i PM <br />xC', r ----j <br />Operational Status Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) (Fill all that apply) (Fill all that apply) :(Fill all that apply) <br />I 5 ' v <br />* Active 41 Passenger ® Generator Q Outdoor <br />-, p O Closed Q Altered <br />GPS Latitude —' , I 0 Hauler Indoor <br />-- - __— 0 Inactive 0 Truck <br />Longitude ii Q Planned Q OTR' Q End -Use Q Container <br />Business Type (Fill all that apply) <br />!� New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government 0 Retreader ® Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br />Q Service Station 0 Hauler Q Agriculture Q Shredder Q Other I I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />0 <br />Q <br />I PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Other: §, <br />Comments Y) ...X ^ 1., ^ I )-^ I _n- f,A-W, A - .. - _L11,.- -.1i - _ f . k_ I1 <br />y <br />I . U1��'y� Yts_, — :, � �t� Se,as��c�a i f Q ., f � huulc r . <br />r A <br />nspection Form Included: <br />Comments Included: Q `BisiSignature <br />uness S <br />Reps ignature Phone Number <br />INSTRUCTIONS ON BACK Co a Incorrect: <br />White CopCIW Yellow Copy: Operator <br />nsp tors Signature _ Phone Number <br />62081 <br />XAMP!L E 1.'2 3 <br />Pink Copy: LEA <br />