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fIDi <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> Cgr.t d -(...4104) Survey Form - Page 1 1 2 - 1 0 1 0 8 2 5 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / .zJ _ Inspection Type (Fill one) <br /> Site Suffix: �Routine QRe-inspection QReferral <br /> Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. (� _ QgGr�,7� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 0 Inspected B <br /> o^SS' 5 P Y Inspector <br /> Physical Address <br /> Gv67- <br /> InspectionDateL p /� <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) .? (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler e Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q 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 H L <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Y <br /> Q 'O PRC§42956-Registration/Decal in Vehicle <br /> - Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirementsr 9 <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 ... <br /> Q 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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ,. K <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § } <br /> Comments . - �� <br /> Inspection Form Included: <br /> Comments Included:Q e r <br /> usiness Rep's S gnature Phone Number Inspector's Signature Phone Number <br /> j ' y <br /> ■ INSTRUCTIONS ON BACK )tt P L• E I, 2 3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> Gt?12_504.(=114 E. <br />