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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ees. <br /> t. <br /> r SaaefWastrnla Survey Form - Page 1 1 3 - 1 0 1 0 6 2 8 <br /> CIWMB 181)N°w 04!04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- inspection- O / Inspection Type (Fill one) <br /> Site Suffix: I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��D� f.(,f,f� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � Inspected By Inspector <br /> �rvi,c a Tri G�e1�s Sq - I' o I `}ems,. �S2 <br /> Physical Address <br /> E, 'fb&,$D k 17�a/� V Inspection Date 2 / © / <br /> /V IL Time In v ✓ Time Out <br /> Business <br /> RRje(p� Title O AM O AM <br /> SoLr,CC U f8h O PM — O PM 1 <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 /> ®Active WPassenger ®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 Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 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 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 a <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 /> Q Q Other: § <br /> Comments - gyp � ;s date <}1 . � „q .+ %s <br /> - is <br /> r KJ,/<_/^���et•^dbDe6/�"t4 � W fP'I.GJ <br /> PrF.0 S iFdr 44)e M <br /> Inspection Form Included:Q �r T�• \ ) �y) �-) <br /> Comments Included: - <br /> flusigililallNeWs Signature Phone Number I s ctor's i slurs Phone Number <br /> ■ INSTRUCTIONS ON BACK r EIX A IM p L 62081 <br /> © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 67081114.0058 <br />