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Waste Tire Survey & Inspection Report Inspection Report NumberStart ■ <br /> CIwM of 181(Ne <br /> Survey Form - Page � 'i'�" �� 5 - 0 Q 6 3 9 <br /> CRNM8181 New 04!04 b_ <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Data <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I t-}- -7 { - Q Routine 0 Re-Inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: ���vh- � �D Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> II � �} � ��� Inspected By Inspector <br /> Phys al dress 4 i 3 / - / c-, I <br /> ��UCX�f�� �- \ Inspection Date / / / / r�1 / O S_ <br /> 'r/1i 2Z Time In ! Time OuttJ <br /> Business Rep Title ®AM O AM <br /> pM O PMJ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -2- D ®Active ®Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I$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 Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. =F' <br /> O Q PRC§42956-Registration/Decal In Vehicle F. <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1(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 <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years A y <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities s <br /> v i;4"OS <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other: § <br /> Comments le l �gss4 G'T/ <br /> 2n +A !6� Ile, <br /> i_„S��1c •Fir-e-3�Ir,, 9'�i r�S�...,e� ;-�. �r�SS�/ /Gss.,� -I�Me S t C'�--- <br /> �'' <br /> Inspection Form.Included:Q r <br /> Comments Included;Q- — � <br /> Business I Signature Phone Number Ins ctor's Signature. Phone Number _ <br /> INSTRUCTIONS ON BACK 1 P .�. � � � 62081 <br /> ■ White Copy.CIWMB •Yellow Copy:Operator Pink Copy.LEA © ■ <br /> 061.0798 <br />