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-F, Waste Tire Survey & Inspection Report Inspection Report Number <br /> t State of California <br /> CMMB astdeMaage Survey Form - Page 1 1 3 - 1 01 0 7 8 4 <br /> California Integrated Warta Management Board <br /> Part A•Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ _ O Inspection Type (Fill one) <br /> Site Suffix: CP ®Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q/1. �LC��_ JOCHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T <br /> Gt-ap,c�, Inspected By Inspector <br /> Physical Address j - r ` /�jU <br /> i <br /> C� �( <br /> Tra 0, / Inspection Date G <br /> � r, <br /> Time In Time Out <br /> Business Rep p Title O AM O AM <br /> V avlce 'Mackey ��i�i� 0 PM 0 PM <br /> / Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f f <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (FIII all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> 0 Q 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 0 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 /> ,.. -..- <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> t <br /> Q Q PRC§42951`Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days o•- y <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 yearsfa' <br /> Q 0 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 x <br /> 02 <br /> ,0,0 Other. § yr <br /> Comments R(oufku laspechlorf I At S. dale• i rtzs' is Cut r r <br /> �a f Sf� � <br /> I� <br /> Inspection Form Included:0 <br /> Comments Included:Q83 <br /> Business Rep' naturePhone Number . In is Sig ure Phone Number <br /> INSTRUCTIONS ON BACK ���IEIXJAJMJPILIEI B(2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0719304.0027 <br />