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€, Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> 1[ State of California - T <br /> CIWMa1"a,t,Mgago Survey Form - Page 1 1 3 1 0 1 3 0 5 5 <br /> Califamia Integrated Waste Management Board <br /> Part A-Survey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- a 9 _ � Inspection Type (Fill one) <br /> Sites uffi X: O •Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: sa., JOat�,l � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Bus* ess or Facility Name V <br /> t^ inspected By Inspector <br /> r <br /> Physical Address 'V / Sad,91)7-4140v,9 <br /> /so <br /> Inspection Date 07 <br /> Time In Time Out <br /> Business Rep Title ®AM AM <br /> 7 0 P 41 � QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) // ^ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (1 0 Active Q Passenger ®Generator ®Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler ®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 •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 ti . <br /> O O PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O 0P <br /> RC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle # P <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> + <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities k <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 O Other: § <br /> Comments7 �� <br /> 9/0 <br /> S <br /> Lt/IGPrLt �O O/ `t<.LY'v— <br /> Inspection FormIncluded:Q <br /> Comments Included: <br /> Business Rep s Si ure Phone Number Inspector's Signature Phone Number <br /> - <br /> INSTRUCTIONS ON BACK E. }f A P L i 2 3 62081 <br /> :V l <br /> White Copy.CIW Me Yellow Copy:Operator Pink Copy.LEA ■ <br /> l_1r2'2;--:A4,A4 <br />