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997. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 99 State of California I - <br /> CIWM8187Management <br /> Survey <br /> Inturvey Form - Page 1 <br /> egrated Waste Managee <br /> ment Board <br /> Part A-Sue y BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i q _1� _ Inspection Type (Fill one) <br /> Site Suffix: C11 <br /> ®Routine Q Re-inspection Q ReferralQ Observation <br /> Local f Referral,choose referral type(Fill one <br /> ) <br /> Identifier: 0 CHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name Ins clad B <br /> B r a n n(�l'i 7(r Pe Y Inspector <br /> Physical Address �3 / om'„,� ` /a `�� <br /> � � tis Clar�ernor�� .��P. - t <br /> _ - <br /> S*C�A n C -P D� Inspection Date O / I / r?l Time In Time Outl <br /> Business RepTitle 0 AM 0 AM <br /> C� y C B(o ��r O PM <br /> ) 0 PM <br /> J �l/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 c5� �J ®Active *-Passenger ®Generator ®Outdoor <br /> O Q 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 /> ®New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 /> rz <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> v <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 <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> .I <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 - <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a <br /> 010 Other: § <br /> Comments _1_1„`1; - -6 (xias rOy� 7 ,� <br /> O';LCt_ri;�I tt .CS 12ef- _rW�e _-DGf -f'b^e oG�woS� ` eS f Ss /l LS <br /> V'1 4e- ed A)O VID10:;h ng njD+td - <br /> Inspection Form Included:Q p / p v(��/ <br /> Comments Included:Q -- q-i-7— /ooV J�`° '�_�W—9%6 <br /> Business Rep's Signature hone Number ��sector's i ature Phone Number <br /> ■ INSTRUCTIONS ON BACK '' <br /> yam1EFI7., ii 2 3 62081 <br /> . ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0723504.0179 <br />