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LC <br /> Waste Tire Sur -ay & Inspection Report Inspection Report Number <br /> C �1_ State of California <br /> Cgrated asteManage Survey Form - Page 1 1 2 1 0 0 8 0 2 7 <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ D 2- 6 / r 0 / Inspection Type (Fill one) <br /> Site <br /> Site Suffix: Q Routine Q Re-inspection 9 Referral Q Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> /A <br /> IPh sical Address <br /> Y- Inspection Date f'> <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> Q PM O PM <br /> Operational Status Tire Type Business Role Storage Type `I <br /> The Count(Whale/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> ) 1 0 Active Passenger S Generator 0 Outdoor <br /> Ci Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O j Q Inactive Q Truck <br /> Longitude — End-use Q Container <br /> Q Planned Q OTR <br /> i I <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Relreader 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 I»NFQRCEMN1°8TA►TliB <br /> iV A I HAULING AND MANIFEST REQUIREMENTS f <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of VlAlatian �?x#etisl4�t <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance 0aa4lino. <br /> Q Q PRC§42956-Registration/Decal in Vehicle IE [D R <br /> Q 1 Q 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I <br /> Q Q (Regtrlted for Nq .orSTj <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 /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Rihfir[nd/P.jW'. <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 /> O Q <br /> f <br /> Comments #yG.✓t�S�{ l l�t Di► c7 il, oq �tr'T 5 4-3 1.✓fr�� <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> 5-2� <br /> usin srCopy. <br /> re Phone Number gnatu Phone Number <br /> _ _.. 620131 <br /> INSTRUCTIONS ON BACt: I �rrbet:. Nf' P L E i T 2 <br /> _ ` _. � � <br /> WWMB Yellow Copy:Operator Pink Copy.LEA <br />