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f� <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> rer <br /> State ( Survey Form - Page 1 1 8 . 1 0 1 3 2 9 6 <br /> CIWMB181181(NewNew 04104) <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: J g p D - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: clout h0mvidQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 Cr - <br /> �j <br /> Inspection Date / `® q� <br /> Time In Time Out <br /> Business Rep /� f� /fl Title p Q AM Q AM <br /> ftej WKC� Sa" O PM Q PM <br /> Operational Status Tire Type Business Role Storage Type .: <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> r r Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> G PS Latitude Q Hauler Q Indoor <br /> O ®Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q 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 O 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 <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 s ftpa a <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 fiq <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 /> 0 Q Other: § . . <br /> Comments Aa C• 1h yj ijoikjiu, <br /> fi got ' irrum k fi U(e <br /> inac fi vc e 7_1V!;br 1 i 6pec�tion Pw yo. , /!.b ✓io"ns &611-ed. <br /> AV-107 <br /> Inspection Form Included:Q - <br /> Comments Included:Q <br /> 89 -- Lf(oS-7D yI) <br /> Business Rep's Signature .Phone Number Insp ct 's Sig_ Phone Number <br /> INSTRUCTIONS ON BACK I ;M P L 1 111213] 662081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> 0723504.0146 <br />