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u Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CfWMf 81(Nrnla Survey Form - Page 1 1 8 . 1 0 1 0 8 1 4 <br /> CgratedW stew nage <br /> California Integrated Waste Management board <br /> PartA-Survey _ BL_U_E_-_O_R_BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 S 0 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S1.1 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> "or Facility Name ^ Inspected By Inspector <br /> Physical gess 3 9 - / �(/ , ���,�✓� <br /> 1717 <br /> Inspection Data / 37 / <br /> 07 <br /> (� Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0 PM 0 PM <br /> '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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O W Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O _ Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 'e/ <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 ' ° <br /> IN <br /> Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 7Q 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 /> t°I 1!i <br /> Q Q 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 <br /> Q Q 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 �fllya� yr1 `TC/n� R/At QGflt/ ✓� GysyJ <br /> 'Inspection Form Included:Q _L <br /> Comments Included:Q - � ` � <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I }( A 1M P L,E 1112131 <br /> 62081 <br /> ■ 0716504.0010 White Copy:CIWMB Yellow Copy-Operator Pink Copy:LEA ® ■ <br />