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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181)N-04104) Survey Form - Page 1 1 6 . 1 01 0 63 0 <br /> Calffomla Integrated Waste Management Board <br /> Part A-Survey _ BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 0 _ _ ) O Inspection Type (Fill one) <br /> Site Suffix: ®Routine QRe-inspection <br /> - <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(R,w joi. In Q CHP Q CIWMB Q Complaint <br /> ""�('^�v`' Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Address Ck t k "t I <br /> J <br /> (/ / /� /1�^r`/� Inspection Date 2 Q a Q <br /> upL�lJ Time In `J Time Out <br /> Business Rep Title jJ O AM O AM <br /> 1°(.C�IYI �,�9ly�t.G'QUI7 �rVl�!-TTJI,✓� O PM O 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 /> f f ®Active ®Passenger i Generator 0 Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS 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 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 C)Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer Generator,Hauler and End Use Facility ' <br /> .,.c„A.._A "iY� 9LU.85. w.Y•S3'Fh'Yi°JF�"?• +l.'biS4'� <br /> Q 1 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires a <br /> Q ! Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q 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 <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 2, w <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § a <br /> Comments <br /> � Yi.VI o <br /> uSG� lire Jnr Was}e :re c� aQ. jriVzJ' far <br /> �¢ <br /> _W05 'MW , tivna��S s a =1abheo f ty CGe tg�11�2- <br /> `s yearS. - <br /> Inspection Form Inclu ed:Q <br /> Comments Included:Q SL�SL _ _ q61? <br /> Business ep's Ignature Phone Number ctor's i nature _ _Phone Number <br /> le <br /> ® INSTRUCTIONS ON BACK jEjXjAjAkjPjLjEj I1 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0f081X14.0056 <br />