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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of California <br /> CIWMB 18ast(New Manage) Survey Form - Page 1 1 8 - 1 0 1 0 6 0 8 <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Detalls <br /> TPID- °� �} ! Inspection Type (Fill one) <br /> Site Suf x: I J - Q <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,irV Q CHP Q CIWMB <br /> Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � . Inspected BY Inspector <br /> ��i k <br /> Physical Address 3 _r 0 I jv-K4 F�zse <br /> SC Inspection Date 0 `[ `7 t�1c�•-lz��-r , CIA �'��/,S v <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> Ii C/ OI t � fr C 0 PM — - 0 PM <br /> Operational Status Tire Type . Business Role Storage Type <br /> Tire Count(W hole/PTE) f ' ` 5- 6) (Fill one only) (F(I1 all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive ®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 ®Trucking Fleet Q Government Q Retreader Q 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 Q Agriculture Q Shredder Q Other <br /> I <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 /> 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 <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 koktthe. jn CfjO✓7 ©tate-- "71AkJj0LAj!rkn WWS <br /> Y <br /> A/fLaIrt WQ TTQ !- &1_ <br /> e U froM & 114490sao a( Q <br /> s s <br /> gtS p _ Uig cc�z�nS <br /> Inspection Form Included:Q �1 <br /> Comments Included: ---- g31 - 3!E u <br /> Bus' ep's Signature Phone Number Ins or's f to Phone Number <br /> ■ INSTRUCTIONS ON BACK i' V ,q P Q E 111.213 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® r <br /> 0708104.0095 <br />