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Waste Tire Su. ey & Inspection Repor. Inspection Report Number <br /> State of CaA/ornla Survey Form Page 1 13 . 1 fl 1 4 7 6 <br /> CiWM6161(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-. Survey _ BLUE OR BLACK INK PEN <br /> Business Profile _ +Inspection Details <br /> ` TPID- f (� G� Inspection Type (Fill one) <br /> Site Suffix: � � © Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> I <br /> Identifier: C1r` � QN� j - � Q CHP Q CIWMS Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name inspected By Inspector <br /> IZ�J 5ec r_Aw%_�- 6�v-f <br /> Physical Address <br /> cA �� � Inspection Date ' <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> /►� Q PM O PM <br /> r u Q.ma� r11�C�i/ r�►�r I <br /> I Operational Status I Tire Type I Business Role Storage Typ <br /> I e <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply)+ (Fill all that apply) I (Fill all that apply) <br /> > > j <br /> ® Active Q Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPs Latitude Q Hauler Q indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — ' • OTR O End-Use Q Container <br /> Q Planned <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility �1 J N jug <br /> __- .. -- <br /> Sion <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires , <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. J <br /> O o <br /> PRC§42956-Registration/Decal in Vehicle �x� <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ` <br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMS <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days �� xr • - <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O + _ <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ^ <br /> Q O !14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators % -- <br /> Q Q Other: § - <br /> Comments G41/ y <br /> US 7 C, 1 -�.� ��,�,1�- roe oUe. <br /> Inspection Form Included: Q <br /> Comments Included: IS <br /> Business Rep's Signature Ph ne Number Ins t rs,Ignature Phone Number <br /> ,:�.. _...�nx•,.,�; ;,Y-%'%J� -�,9- 62081 <br /> INSTRUCTIONS ON BACK <br /> :IMI F L E t <br /> .:" <br /> White Copy:CIWMB 'Yellow Copy:Operator Pink Copy:LEA <br />