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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClWM f 81(Now Survey Form Page 1 1 101 4 8 29 <br /> CIWMB 181(New 84!641 � r <br /> California Integrated Waste Management Board <br /> Part AL- Sctrvey_ _ _— -- _ BLUE OR BLACK INK PEN <br /> IBusiness Profile Inspection Details <br /> TP1D- — — - - - - — Inspection Type (Fill one) — — -- - - -- <br /> Site Suffix: ` -� I# Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifiers - I0 CHP Q CIWMB Q Complaint O Educational Visit Q Other I <br /> Business or Facility Name <br /> Inspected 8y Inspector + <br /> Apt �v4-�rcc-� - o <br /> Physical Address <br /> r� Inspection Date <br /> v r / t � I I <br /> 'o l I <br /> ITime In Time Out <br /> Business!Rep ` Title Q AM Q AM + <br /> 0 PM M <br /> QP <br /> — <br /> - - — - Operational Status I Tire Type � Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply)l (Ffif all that apply) I (Fill all that apply) <br /> 0 &Active &Passenger ®Generator I Ig Outdoor <br /> - — 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler I Q indoor <br /> O Q Inactive l Q Truck <br /> Longitude - I Q Planned Q OTR Q End-Use Q Container <br /> I Business Type (Fill all that apply)- <br /> f Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel f <br /> IQ Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility <br /> - ✓lis.,.,,. sy is•- - - :`ii :�'..,,. ham;;; .•�•.;oqr./' 'js�.';/'����%i`.::�,/:J"%`s�%..�' ii %' '�9 "/% <br /> �' jos' � I ;�� �?S.�P��� i'/._ /�i''i,;/��C /`��`/% ��;/ �� j� �i .,iii i-✓i,/ ..�j/' / � ,/a,ir <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements � �' 9511-115 L <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 'y <br /> O O 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> C) Q 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' igw <br /> ✓ <br /> Q o Other: § q <br /> comments f� r <br /> ► �- <br /> _ _ _ w� ,,Lb��, � <br /> Inspection Form included: 0 <br /> Comments Included: Q — — �r��� <br /> i illness Rep's Signature Phone Number Ins actor's Signatu e_- _ Phone Number <br /> INSTRUCT BACK s y 0�711 <br /> °.`; ++a p (� �Z3 62081 <br /> �, �g <br /> ( <br /> Kb White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> JI 9 <br />