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Inspection Number <br /> eii <br /> Waste Tire Survey & Inspection port ■ <br /> 0��I State of California <br /> CWMB 1steManag) Survey Form - Page 1 mj(c d z6p,- 0 0 8 0 3 0 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLI_E OR BLACK INK PEN <br /> :Business Profile I Inspection Detel(s- <br /> TPID- � � � � � � - � � Inspection Type (Fill one) <br /> Site Suffix: � 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 64 rl-�&I ak-Gs <br /> Inspection Date / / /� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 'C? (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> >i !Active 9 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 /> Q New Tire Dealer 40 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 f ANFQlf� NT1� <br /> t/ A HAULING AND MANIFEST REQUIREMENTS _ Q Nf�tlofR;�Tt Yl0laflgl>� !�:���g�tl�g <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. COIYtpllanRt) dllr� ' <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 /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Ftp ,tl/Re��pPl�� OPT} <br /> 0 . 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers QiC�lf�� j f f0004", <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ri <br /> / ' rJ �/ <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators /� <br /> O Qig� <br /> Other: <br /> �j✓y;// %%�� <br /> ..Comments ��l/i-�'v (il,°✓Q� � �"Ir/[.J 1/1�1 � ) _ C) 1 y`j�n'� (.✓`1 Jam' �� �1^e— <br /> 1, rnakie,- f f <br /> tyr.r?ty -- <br /> Inspection Form Included: Q 4. �r�Qd/ <br /> Comments Included: Q ! 7Q� <br /> Busin Rep's Signature Phone Number In t r s S gnature Phone Number <br /> � � r 62081 <br /> INSTRUCTIONS ON BACK G �BCt: ��1FE@Rt +�( I �C�A`.fIJI�PrL ��1 2I � <br /> While C y:CfW Yellow Copy:Operator Pink Copy:LEA © ■ <br />