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■ = , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Callfomla <br /> CIWMB 181'New 114104) Survey Form - Page 1 1 1 - 1 0 0 6 7 0 7 <br /> califomia Integrated Mate Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- - I✓ / 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: a,I't_TWgWn Q CHP Q CIWMB Complaint <br /> l7>J"_ Q Q Educational Visit Q Other <br /> Business or Facility Name <br /> �OI''�►1U�5�InG#jT;t� Inspected By Inspector <br /> Physical Address 3 - r o 'TaeuLL <br /> I '�D,51 L- chap--�;� �,y <br /> `S` C to n G Inspection Date ' ! ut O <br /> -(� 1 Time In Time <br /> e Out <br /> Business Rep Title 0 AM 0 AM <br /> O 3 S PM O ` ff PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 01 Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f *Active ®Passenger *Generator Q Outdoor <br /> O Q Closed ®Altered <br /> GPS Latitude Q Hauler I Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ®OTR Q 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 Dismanfler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber I���� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other rJ �}�� <br /> y V4Q PvKW <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility r� ' <br /> j 4 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires "z d <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ' .;. <br /> u <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements n n <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 /> ,a,a4• <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 /> t <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § <br /> Comments <br /> am WOW V.125t es L1VD? Tk�e Pr ,err <br /> a Ui o a4-° nS. <br /> Inspection Form Included: �'qjq r t c r <br /> Comments Included: - l <br /> IYep"s Signature Phone Number Ins �.t.r' ntePhone Number <br /> �.r Lk �, ,��a62081 <br /> INSTRUCTIONS ON BACK " :> _ $t I� X A ddt P L1112131 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br /> ® ■ <br /> 0r,41 A44_i4,4_7528' <br />