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a <br /> =vo, Waste Tire Survey & Inspection Report Inspection Report Number <br /> r>< State of California <br /> CIWMB 18asteManage Survey Form - Page 1 1 1 - 1 0 0 6 3 9 2 <br /> California Integrated Waste Management Board <br /> PartA-Surv_ey_ _._ __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID-ffip Inspection Type (Fill one) <br /> SiteSuffix: � -7 4 t, / 0 j Q Routine ®Re-Inspection Q Referral Q Observation <br /> Local If Referral,choose referral type.(Fill one) <br /> Identifier: Tee�JD Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Z7 Inspected By Inspector <br /> 4_4 Lj"11 <br /> Physical Address <br /> mal. <br /> Inspection Date ® / L 57 / 05 <br /> Time In Time Out <br /> Business Rep Titlez O AM O AM <br /> 0 J (0 PM ® 1'�' ®PM <br /> 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 /> ®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 /> Buslness Type (Fill all that apply).. <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 /> IL <br /> Q ..0 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 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 /> j+ <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 . <br /> s <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q Other: § y <br /> Comments R _ ,- Q � 4r^n,—. �w.. 11, C�'.���fr__r_ � _)/� 4 7 a Qf <br /> �jj .n�l -71,I5 sO--e, f r r i1�1cis Il <br /> U -Fv f 1 ? <br /> Inspection Form Ibcluded:Q tell, <br /> Comments Included: Buslness.Re' Sig e Phone Number' Insors <br /> PhoneNumbee <br /> 62081 <br /> ■ INSTRUCTIONS ON BACKarreCt X. i+4 ( P (. E 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />