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dWaste Tire Survey & Inspection Report Inspection Report Number . <br /> State of California <br /> Cgnat d tit. .—ij. Survey Form - Page 1 1 3�- 1 0 1 3 4 2 4 <br /> Califomla 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: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �.^ If Referral,choose referral type(Fill one) <br /> Identifier: �jj1 70l t yl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> V ,IP..,�5 � rI•� <br /> Physical Address <br /> Crays ffcc✓I�-s�l /�� <br /> CL, Inspection Date I / <br /> rPr 1� 3I <br /> Time In Time Out <br /> BusinessRepTitle ®AM 1 O AM <br /> � D O PM I oC D Li ®PM <br /> Operational Status Tire Type Business Rale Storage Type <br /> Tire Count(Whole/PTE) ,V <br /> �` (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 /> Latitude D Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 ® Inactive Q Truck <br /> Longitude — — Q Planned— Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) —L— <br /> Q New Tire Dealer Q Auto Repair p Trucking Fleet p Government p Retreader p 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 O <br /> 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 O <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 _ U <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 Other: § <br /> Comments Qfwft e 1 h r Ti bitil <br /> AD e s ho"f- gnt� <br /> eefrate., it -We-s <br /> r-a nn Wc�s cLi sc,4sse d ki <br /> "akee- I-ii <br /> S h fl�� 'Yes 11����Cc-1�: Sh I I >�. r'� ii S�'e✓/1ec.�q�.t �; <br /> Inspection Form Included:Q <br /> Comments Included:Q' <br /> Busln Rep's Signature Phone Number Ins clot"s nature Phone Number <br /> 162081 <br /> INSTRUCTIONS ON BACK X 14 A� P 1 .2 3 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0605204.0550 <br />