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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Sta Mto <br /> Ca <br /> MMB <br /> 811(New 04/04) Survey Form - Page 1 1 22- 1 0 1 3 3 4 4 <br /> CMB 1 <br /> Califomia Integrated Waste Management Board <br /> Part A-Survey. BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l D 7 (� g' - 1 Q Routine Q Re-inspection Q Referral Observation <br /> LocalCom` . If Referral,choose referral type(Fill one) <br /> Identifier: JdA L.e— Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 <br /> 124 <br /> � Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> , ) b L, ' S S aPM 0 P <br /> Wdg 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 /> L ° 0 Active ®Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ®Truck <br /> Longitude - J Q Planned I Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler QDerived 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 rX <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <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 Q 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 /> 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 /r �f`�C ��t "C7�S lY'9QLs�11+� O / lR•�� S�+C 4N _ <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> B Ins ep's Signature Phone Number Ins .tor s Sign re Phone Number <br /> INSTRUCTIONS ON BACK jIEj*jAjMjP1L1E1 1112131 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0603104.0171 <br />