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ii <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181Waste <br /> eManageI Survey Form - Page 1 1 4 1 0 1 3 0 8 6 <br /> California integrated Waste Management Board <br /> Part A-SUrVey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID' j n - O inspection Type (Fill one) <br /> Site Suffix: ` l/ oaio_ <br /> Q Routine ®Re-inspection Q Referral Q Observation <br /> Local n If Referral choose referral type(Fill one) <br /> Identifier: f;{, Q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> kt <br /> 'Physical Address <br /> Inspection Date �,) ( / �� � / C) ) <br /> OJ Time In Time Out <br /> Business Rep Title O AM O AM <br /> QPM QPM <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 ®Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 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 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 ®Other Rp"dur s,pbrisSjce �k ' <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility " <br /> Q 'O` PRC§42951-Waste Tire Hauler Registration and Transport of Tires . mz <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. t' <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 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 . is <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> ?t '. <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 r•, & .. <br /> µ <br /> Q 1 Q 1 Other: § �R <br /> Comments ivtch. -Or -611DO&\C? .17QS E1 U-zCt <br /> is a (ovv- Ua 1 kxy)e- V',ia ,f fiirt <br /> All �nnaL �i rL 1 saL1 t r n ? DF l eS.s :*-o-pt <br /> -dires� ace w ,rfed rt ' 1-S- Nem act ess�as�� 11l, Sacxa eyt�a <br /> Inspection Form Included:611 <br /> (J �� <br /> (� .KP.�•t <br /> Comments Included:Q— ( <br /> loess ReVs Signature Phone Number I p or's g ature Phone Number <br /> INSTRUCTIONS ON BACK > ElXJAIMI P IL E 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />