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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ofCalifornia Survey Form - Page 1 9 . 1 0 1 0 7 0 8 <br /> CIWMB 18 <br /> 1 <br /> New 04104) <br /> CaliforniaalifoInteggratedratedWaste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> . TPID- ' 3 (� q �y ! / Inspection Type (Fill one) — <br /> Site Suffix: / O� 0 1 <br /> ®Routine QRe-inspection QReferral <br /> Q Observation <br /> Local V If Referral,choose referral type(Fill one) <br /> Identifier: - Q CHP <br /> Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> f�,f Cast C�re�e 3 � _ l o � <br /> Physical Address <br /> /r / kh rt /1�(�- �]15 0 / Inspection Date 0 C) / /1 <br /> r`�-T�TVR / 1 'fE�� Time In Time Out ('J <br /> Business Rep Titled /� O AM <br /> I <br /> �j rjv( �UcIL�V/C2 O AM Qr - - O PM O PM <br /> + nkbd�- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Passenger Q Generator Q Outdoor <br /> eGPS Latitude O Q Altered <br /> Q Hauler Q indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill ail 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 /> a. w <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 /> QQ PRC§42953-Contracts with Registered Waste Tire Haulers. 7 <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q ) <br /> 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-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 <br /> 14C R§16460.2-Manifest System Requirements for Registered Waste Tire Haulers ` <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities w 4 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: <br /> is aril A <br /> Comments PVkW*te1GlS G `5 - I/b / ae <br /> -A ' or Nd e dc's ,c <br /> `s e ' • tz� t, `IoM�lgwnqs Ld 11L <br /> td 7P/QW <br /> ail- <br /> Inspection Form Included:Q n <br /> Comments Included:Q a -JAn1'` <br /> Business Rep's Signature. Phone NumberInsp or's SI a ure Phone Number <br /> ■ INSTRUCTIONS ON BACK E M P L E - $ 62081 <br /> 0716504. 00-5` White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA © ■ <br />