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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California Survey Form = Page-1- - 18 - 1 '0 Q 6 3 4 <br /> CIWMB 191(New Y <br /> CaliCaliforniaIntegrated Waste Managenage ment Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site suffix: 1 3 O '$ 0 .57 "-7 - d l ®Routine Q Re-inspection Q Referral: Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: DL.+>r ,e><� �� .. Q CHP Q CIWMB Q Complaint Q Educational-Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address � <br /> S <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep L Title Q AMQ AM <br /> - Operational Status!Tire Type Business Role, Storage!Type <br /> Tire Count(Whole1PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fiji all thatapply) <br /> ®Active ®Passenger. ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS LatitudeQ Hauler Q Indoor <br /> O Q Inactive I%Truck <br /> Longitude - Q Planned Q OTR Q End-Use 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 Q Car Dealer .Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®'Other 1 <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 7 <br /> O Q .PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle 4. x <br /> Q O <br /> 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 ., ;.. �bE ,,., ,, •` ., ,w�., f „ <br /> Q IQ 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within.90 days r <br /> Q Q 14 CCR§16459.3-Retention of Manifest-Forms and Tire Trip Logs for 3 years <br /> Q Oo� <br /> 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 ' fF <br /> Y <br /> Q Q 14 CCR§18462-Manifest System Requirements For Tire Dealers.or Waste Tire Generators <br /> Q QOther: § / a r .°a <br /> comments. (rf y h�18�Q �e� " t � � Z�zz_d2 53� <br /> Pnfprled <br /> KB <br /> Inspection'Form Included:p <br /> Comments Included:Q - - � ` _ Zi 1/6 <br /> us as s Rep's S!' {ure ;'. Phone Number Ins is Signature < Phode'Number' <br /> 62081 <br /> INSTRUCTIONS'ON BACK L .AIMIPME1 <br /> .eo <br /> ■ White Copy:CIWMB Yellow Copy: <br /> Operator Pink Copy:LEA. ■' <br /> F`1529204.0040 <br />