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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> EE9 <br /> Sir State of California <br /> CWMB g,.t.d W.M. a aGge Survey Form - Page 1 19 - 1 0 1 0 8 0 r' <br /> California Integrated aste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O Inspection Type (Fill one) <br /> $Its Suffix: 0 Routine O Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��yL p�0.2 7� O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Buss/iinne�esss or Facility Name p Inspected By / Inspector <br /> Physical Address �! 3 / — ® / P&fA,__�w �✓i <br /> /1 <br /> Inspection Date � � / / (/ / tom' 7 <br /> Time In Time Out / <br /> Business Rep Title O AM Q AM <br /> JW ev / O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE)` O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> E i Active 0 Passenger ®Generator ®Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O O Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair ®Trucking Fleet 0 Government 0 Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber <br /> 0 Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle , , <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements �• <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 daysj: <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years _ <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers t <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> " x <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 1 Q 1 Other: § <br /> Comments •,1 <br /> Inspection Form Included: Q <br /> Comments Includ - -- <br /> B mess ep's'Signature Phone Number Inspector's Signature Phone Number' <br /> u 62081 <br /> ■ INSTRUCT ONS BACK �s c€1 v a� A jAii 1 <br /> Gi T i r.5 Ci 4 171171171 White Copy:CIWMB MB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />