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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 11{ state of California <br /> CIWMB 18eaSurvey Form - Page 1 l 2 - 1 0 1 3 7 8 6 <br /> Californiaa Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . <br /> TPID - O I Inspection Type (Fill one) <br /> Site Suffix: � 8 ` Q( ®Routine Q Re-inspection Q Referral Q Observation <br /> Local / / If Referral,choose referral tYPa(Fill one) <br /> Identifier: J` QCL�( � c l,"p+_iTf�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 'I _ <br /> ;,,,�,',tS�"� Inspected By Inspector <br /> Physical `` less <br /> /3`�� <br /> Inspection Date p / /c0 6 / 06 <br /> v ���JJJ <br /> Time In Time Out <br /> Business RepTitle ���+ O AM Q AM <br /> 1��l [Lby- C5"�'�' O PM 0 PM <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 /> a ' Q Active Q Passenger Q Generator Q Outdoor <br /> O 1*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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader O 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 .Other I Q►^T� <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility y <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport ofTires <br /> a t <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. r dY <br /> O 0. 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 a r v <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 r i' <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments ' f yt Ol <br /> does hot ayn"ee- waste -&ts. Ep�p mani and parft sn Loi Oh <br /> _ �,-ik arej new. AecommeA j -/a Clone Ac►,c`.1,i-f-L�l'� <br /> GLIM _ <br /> Inspection Form Included:Q ,~/ 7—,�)/� <br /> Comments Included:Q �✓��/"-y fc� <br /> Business Rep's Signature Phone Number I actor ignature Phone Number <br /> ' 62081 <br /> INSTRUCTIONS ON BACK r E XAIMIPILIEI <br /> 4 � <br /> ■ While Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0618604.0434 <br />