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seg <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate orn <br /> of Califia <br /> CIWMB 18eM_,ge <br /> Californiaurvey Form - Page 1 1 9 - 1 0 1 0 7 3 2 <br /> ifornia Integrated Was-tte Management eoartl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - O Inspection Type (Fill one) <br /> Site Suffix: 1 cL / ®Routine Q Re-Inspection Q Referral Q Observation <br /> Local /` If Referral,choose referral type(Fill one) <br /> Identlfter: l�/`►yt` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> V A,,��/�G C�� �� Inspected By Inspector <br /> N -��y/� <br /> Physical Address 3 - ' Q 6. ' "`�-e <br /> S(rn n VV_ <br /> C / C�� C4 G����� Inspection Date <br /> --�'rIfC31, / Time In Time Outt <br /> Business Rep /,�(. l,,/ - Title Q AM Q AM <br /> } (act PC- C rf C� P' 0 PM Q PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) e r 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Passenger ®Generator Q OutdoAAorrr <br /> Latitude <br /> O Closed Q Altered (114 I <br /> GPS Q Hauler Q Indoor <br /> O *Inactive ®Truck <br /> Longitude _ Q Planned OTR O End-Use Q Container <br /> Business Type .(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreada Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber t^ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other ✓I �/��,r,taC <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q y PRC§42951 Waste Tire Hauler Registration and Transport of Tiresa �a 3� <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O <br /> PRC§42956-Registration/Decal in Vehicle �•��'`��,�''• <br /> tQ 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 CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r 1 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities G'^ <br /> w` <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 O <br /> Other: § <br /> Comments I 70ll was I „ <br /> v at <br /> i a ►�-vo ter 1a fe �Ye e `�.f S W�l o Wal 71-� &r <br /> SWViLO_ otis�oSo.Q• a_ -1 S VI'tWed anon T- Q Pro (u4, c Sc.c,SSecd s l ec- <br /> (J•✓11"\P_it.(Y 'o iMacf1rare )-P10'# To No V 10 S us-yKl' <br /> q <br /> Inspection Form Included:Q ��y/ <br /> Comments Included:Q <br /> siness RepAs Signature Phone Number _cto s Ignsture Phone Number <br /> INSTRUCTIONS ON BACK _ 3 _ a _ y X A M P E 2 62081 <br /> ■ 0716504.0045 White Copy CIWMBs Yellow Copy:Operator Pink Copy:LEA ® ■ <br />