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E <br />E <br />r- <br />■ <br />in Waste Tire Survey & Inspection Report Inspection Report Number <br />state of Caln.-m a <br />cIWM6ana181(N-04104) Survey Form -Page 1 i 6 10 13 5 4 2 <br />Californla Integrated Waste Mgement Board <br />'art A- Survey _ BLUE OR BLACK INK PEN_ <br />3usiness.Proflle <br />TPID - �} <br />Site Suffix:/ <br />Local <br />Identifler: <br />J i'~ <br />Business or Facility Name <br />Phys <br />tca' I Address cJ <br />Lox <br />Business Rep Title <br />Tire Count (Whole/PTE) - 2 0 <br />0 <br />GPS Latitude <br />0 <br />Longitude — <br />Inspection Details <br />Inspection Type (Fill one) <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector y� <br />3 % / o l _' Jai S <br />Inspection Date © c-/ / , 6 / b <br />Time In ZS Time Out b <br />O AM 0 AM <br />O PM 0 PM <br />Operational Status Tire Type Business Role Storage Type <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />0 Active 0 Passenger ® Generator ® Outdoor <br />0 Closed 0 Altered <br />0 Hauler ®Indoor <br />0 Inactive ® Truck <br />0 Planned ® OTR 0 End -Use 0 Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />0 ' 0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />u " * x _7. 74. r <br />0 0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />a 1Je 1d <br />0 0 <br />PRC § 42956 - Registration/Decal in Vehicle,. <br />- <br />F <br />0 0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirementsr <br />T <br />0 0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />ti.;vF <br />0 1 0 <br />1 Other: § <br />Comments I ✓1 _ .IF b Ida- <br />A5 <br />5erg c> 4L 1 5 -20 tQR��� <br />�ZJ � � �ti�•CQ��-�Y Str �i-�5 :^�s��.r�^�'i'G-�ia���C or i'�CF <br />Inspection Form Included: <br />�IBuines <br />Comments Included: gnature Phone Number Ins�AJMJ <br />'s Sit <br />�INSTRUCTIONS ON BACK. E P <br />■ While Copy: CIWMB +Yellow Copy: Operator Pink Copy: LEA <br />062E:'304. <br />Phone Number J <br />62081 <br />® ■ <br />A <br />