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nspection Report Number <br /> Waste Tire SAey & Inspection Repor" I <br /> State ofCallfornla Survey Form. Page 1 2 - 1 Q 4 $ 6 <br /> CIWMB 181(New x age �. <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: r 7j 6 d 6 ®Routine Q Re-inspecti n Q Referral Q Observation <br /> Local If Referral,choose referral tyP (Fill one) <br /> Identifier: ��-� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhyI Address - t <br /> _7701 <br /> r q Inspection Date © <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM 0 PM <br /> 1 1'al�i Operational Status Tire Typi Business Role Storage Type <br /> The Count (Whole/PTE) © (Fill one only) (Fill all thatapply) (Fill all that apply) (Fill all that apply)', <br /> J • Active • Pass 3nger ®Generator Outdoor <br /> � Q Closed Q Altered GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truc <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I* 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility lT BTU <br /> /', - <br /> O O U � J �i 0 ton <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires / <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CfWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers - e <br /> j:. <br /> O O 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 [_ t <br /> �[r-t �/,T'y �� C.�C'M-G�1�'ir�� � (�,,1"'`� l l"�.s` C•� fnnav��1.--- <br /> ol hA G "IIA 11 g !- G�� �Jt.�-�l0 v6AeN+^143 4-r r. l o s c) -n <br /> �' fi� u - r ��.�� t ra a - 6 116 N <br /> CL <br /> Inspection Form Included: Q <br /> Comments Included: y►�RI"�C — �- —� j -- (� <br /> Business Rep's Signature Phone Number In or's S gnature Phone Number <br /> NOW <br /> ;yla "t`y�' ' ' ;�' 62081 <br /> INSTRUCTIONS A, P L E <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LE AA <br />