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Waste Tire Sl ey & Inspection Repor, Inspection Report Number <br /> - <br /> StataedWafornia Survey Form - Page 1 1 1 4 0 8 01 4 <br /> CIWMB 181(Now 04104) <br /> California Integrated Waste Management Board <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I [7 3 -7 <5 -7 r Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> o or /{ ; <br /> ��- ' <A �. <br /> Inspection Date 0 6 <br /> Time In Time Out <br /> Business Rep /f Title C) AM O AM <br /> )ZL"Vi, /�! 1 'Or+ v jt:Pi �l'77 O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) �` 1J� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> C 40 Inactive Q Truck <br /> Longitude — Q Planned Q OTR O 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 Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 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 ENFOR90110 <br /> V ; A HAULING=AND MANIFEST REQUIREMENTS <br /> Q i otloo. . VI 111t�r �s►J#r It <br /> Q ! Q !PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C�ft7pilat%os� Dgl�n�/, / / <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements C1at$ r <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB t <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 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 /> Q I O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: ...., <br /> Comments revci'(Ar l/�K3 A !jt-+� I !t� ►'ylr.�— l�J.J ljlvl - - D� 6ee*;L ,/y - <br /> •�f 1�7Xfh�[;'fN.� �� wG: (✓ I1 '�t�`Q / <br /> 1 Inspection Form Included: Q G�Comments Included: Q <br /> B siness Rep's S nature Phone Number/ .to <br /> Signature Phone Number <br /> INSTRUCTIONS ON BACK �Co `:ilfEG9'dCE: ( /} � R' P iT3620811 <br /> While Cop .CIWMB Yellow Copy:Operator Pink Copy:LEA <br />