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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> n State of California Survey Form - Page 1 1 3 1 Q 1 0 5 2 <br /> CONMB 18W1(New Management California Integrated aete Manageent Board <br /> Part A-Survey_ _ _ BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- I �� - I Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type one) <br /> Identifier: `Y/}t .� Q CHP Q CIWMB Q Complaint <br /> laint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address3 "I / (7 / t� Flkq " <br /> A"Zi 4d <br /> 9"Sg[J i'� c r i Inspection Date 0 -2 <br /> �l VC�1 U 3 <br /> Time In Tlme Out <br /> Business Rep Title O AM Q AM <br /> 11 o 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 /> r v ActiveQ Passenger t&Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler to Indoor <br /> 0 Q Inactive (9 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 0 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 /> 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 s <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 c' <br /> 9.24.`*i:n� -,�'��'r ✓ <br /> 14 CCR 18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q § Y q <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ` <br /> Q Q Other: § <br /> Comments kau&v- f�S `S Qr � UAS Ploted <br /> e , ►,rrrc -�ry� aQ N� <br /> Inspection Form Included:Q I� Q <br /> Comments Included:Q - - 94 -2"6'" �n.t.r. '��J <br /> us ness ep. ignature Phone Number Ins ectPhone Number <br /> INSTRUCTIONS ON BACK t � / p �j 1 j Z 13 6281 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0723504.0175 <br />