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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ClWM(California Survey Form - Page 1 12 - 1 0 0 7 3 4 <br /> CIWMB 181(New nage <br /> Calltornla Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- - O / 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: j��J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> mow- 'I -Q s 3 - r o r J froom <br /> Physical Address <br /> A Inspection Date D 5 � I � / D(•� / Time In Time Out <br /> Business Rep Title O AM O AM <br /> y�1.a� np c p PM - O PM <br /> ��J1( '�C J 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 /> r r ®Active 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 /> IQ0 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 ow— 'P6 Ca -- <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (D Other RtAr VV60br;Ve +C Q,�;3i1eS <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 s a <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. x - <br /> Q Q PRC§42956-RegistrationlDecal in Vehicle '` <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements rN <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 r e` <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 .�Y. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other:-§ <br /> Comments <br /> r�z(1 r S �� lt( <br /> 4 ILA Af <br /> ilka <br /> ( es I&- <br /> [Ye S A o V( 11-0f m <br /> Inspection FormIncluded:Q <br /> Comments Included:0 Ute/ <br /> Business Rep's Sign re Phone Number Insp s Si�- - <br /> INSTRUCTIONS <br /> ON BACK 1EjXjAj'MjP1L1Ej 1112131 <br /> 62081 <br /> ■ 0716504.0042 White Copy:CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br />