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3- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> at03;, state of California <br /> r - gWM8187st(New Manage) Survey Form - Page 1 14 - 1 G G 6 3 8 7 <br /> California Integrated waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details: <br /> TPiD_ /// Inspection Type(Pill one) <br /> Site Suffix •Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� O CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name -- —r <br /> Inspected By Inspector <br /> Physical Address <br /> Z49 - <br /> / �y Inspection Date O © / z3 sc— <br /> �� <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> r lT J�–�ies Operational.Status Tire Type . Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fll all that apply) (FI li.all that apply) (Fill all that apply) <br /> 0 Active I*Passenger ®Generator ®Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler Q Indoor <br /> o Q Inactive O Truck <br /> Longitude – O End-Use Q Container <br /> O Planned O OTR <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O'Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other — <br /> Part B Inspection of Waste Tire Dealer Generator Hauler and End Use Facility q' <br /> I xzn:*y.S"OW <br /> ie `aS�.r*��S4'-.-.'' <br /> O O PRC§42951 •Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. , ➢r. ; <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> <.�... max,.•�.• x,z: <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB sem. <br /> O 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 w �a <br /> O O .: . <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers.. <br /> O O <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 1 Other. § <br /> Comments <br /> r t O 5; 2.U`6 .1,4-X <br /> St�f'G _ (nig 'L -?O L-04 -�f't 5;-,Ire-. Entered <br /> d e,>�g-F� .mss , KB <br /> Inspection Form Included:O <br /> comments Included:. <br /> usines ep's.Signature Phone Number - rJnsp s Sign tur Phone Number <br /> -- �� 62081 <br /> INSTRUCTIONS ON BACK GoCfe>z �grect r t P 1 : 3 <br /> ■ White Copy:CIWMB- Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0529204.0039 <br />