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"aa Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> ■ saa� <br /> of <br /> C1WM Survey. Form - Page 1 1 4 - 1 0 0 6 4 12 <br /> CIWMB 781(New 04!04) <br /> California Integrated Waste Management Board - - <br /> Part A-Survey _ _ _ BLUE OR BLACK INK PEN <br /> -Business Profile -- Inspeltion Details - <br /> TPID- I O - Inspection Type (Fill one) <br /> Site Suffix: l 1 3 D O Routine Q Re-inspection Q Referral Q Observation <br /> r- <br /> 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 <br /> T ` Inspected By Inspector <br /> P ys caI Address - 1 O, <br /> J <br /> ._ _� w. l <br /> Inspection Data 7 <br /> Time In Time Out <br /> Business Rep TitleO AM j O AM <br /> O PM O <br /> Operational T <br /> Status - ire Type Business� . <br /> pe <br /> V <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> Storage.Type <br /> �✓l �~ <br /> Tire Count(Whole/PTE) [� apply) (Fill all that apply) <br /> f ( � ®Active S Passenger 9 Generator rOutdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) . <br /> Q New Tire Dealer Q 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 ®Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ''IrNFaFGE�IIENi'STATUS <br /> -� . <br /> �... :� .,- ''� . ; ., - �.•".. Notice Df V <br /> Q 'Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires r w <br /> x F� <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. itGe Deadt „ <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 Numberfrom CIWMB 1 ONE 1111 <br /> Q Q 14 CCR§.184592.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days : <br /> 0 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 r R <br /> Q Q 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q i 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q j Other: — <br /> Comments \�u�t g L 5 <^•C.�s,�i�t,.�11�,,y�a/��•ar�R ?!�(`�dl,, <br /> V t o�Qnlly 3 r 6ft ce`v\ <br /> Inspection Form Included:Q. <br /> I Comments Included: 3 765 <br /> 1 Business Rep's Signatur o W-rinber In Signature Phone Number <br /> INSTRUCTIONS ON BACK ��' �� $ ' M P L .' g ? --62081 <br /> ■ CIWMB ® ■ <br /> White Copy: Yellow Copy:Operator Pink Copy:LEA <br /> 0525804.01.6 <br />