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nspection Report Number <br /> Waste Tire Suri _y & Inspection Report <br /> rrr StateedWaof California Survey Form - Page 1 14 7 5 <br /> cIWMa tiati thaw oarool <br /> California Integrated Waste Management board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> f Tplp_ Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local ter. If Referral,choose referral type(Fill one) <br /> Identifier: J , �.�Y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name inspected By Inspector <br /> � <br /> ,,2_-7; <br /> Physical Address 3 C/ <br /> j q z3 � cls L� <br /> Inspection Date I 2 J 2— / <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> QPM QPM <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 /> } Q Active Q Passenger Q Generator Q Outdoor <br /> D S Closed i Q Altered <br /> GP$ Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> 4 <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EKQtGEME( � T <br /> 1f HALF a AND MAN 11101ST'-REQUIREMENTS !ON otice Qf Ylal;ttl>pn <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compjlanco dl E70 <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements I Date <br /> Q 1 O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 Submittal of Manifest Forms and Tire Trip Logs within 90 days (Rgttllec' r{�fQ�hl ' � <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§ 1 B460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Etrl`ett i1rk1 $ tR � <br /> 09 <br /> O 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilities r �' <br /> O <br /> 0 <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste The Generators <br /> Other: <br /> Comments /� �C�✓ 6 t„�1 v3 5 Cq "G+�S Gjd'+-�b jjq <br /> Inspection Form Included: QI ' <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Numb'er,/ a or's Sign a phone Number <br /> INSTRUCTIONS ON BACK [Colif LXX A M P � 62081 <br /> White Copy:Cita MB Yellow Copy:Operator Pink Copy:LEA <br />