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ids;. Waste Tire SL. ey & Inspection Repor%, Inspection Report Number <br /> QState of California <br /> CWMIB grated 1steManage Survey Form - Page 1 d 2 7 8 <br /> California Integrated Waste Management Board <br /> Part A. Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 2 (4- 6. 3 3 d t 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local +/ If Referral,choose referral type(Fill one) <br /> Identifier: r (DCHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physl al Addr ss d � � �e.ts <br /> � s G t CAr <br /> CA 9S2o 6 Inspection Date D I Z S ' Q C <br /> Time In Time Out <br /> Business Rep Title O AM C) AM <br /> Q PM 0 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 0 Active Q Passenger 0 Generator ® Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 inactive 0 Truck <br /> Longitude _ Q Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair�Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN00"COMEMT VATU8 r _- <br /> V A' HAULING AND MANIFEST REQUIREMENTS i O tptIuu fJF Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Co_ tl-nce Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirementsq{ <br /> Q 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program iD Number from CIVVMB <br /> (1 �qulred f r NbV or EXE <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 1 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years " <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers niQrcomont <br /> Q 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities �y <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 4 I <br /> - 1p1(pn ae No.Vlalmtlons I <br /> O 010 <br /> § {t F <br /> Comments �.� L—A;y al+ <br /> (la-., ,yr'/.5 tnJ.,�_ fi Lj,,4— *;yv_5 t. 'r- - U►f 17✓4S�'�'� <br /> . <br /> Inspection Form Included: 0 , <br /> Comments )nc)uded. 0 <br /> B iness Rep's Signature Phone Number <br /> � Ins ctor's + re Phone Number <br /> INSTRUCTIONS ON BACK Corri�t, Irt�arr� #� ( Y� Lf ,V ��4 hti�p (_�fmr � s2os1 <br /> Entered <br /> KB White Copy:CIW M6 Yellow Copy.Operator Pink Copy:LEA <br />