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WE <br /> Waste Tire Su&y & Inspection Report• Inspection Report Number <br /> Stattt; '� CIWGM ofCalifornia Survey Form - Page 1 3 - 0 2 61 8 <br /> CIWMB 181 stew 04104, Y J <br /> California 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: r 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local —c^r~ If Referral,choose referral type(Fill one) <br /> Identifier: � � � ''� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> I i Inspected By Inspector <br /> Physical Address 3 C1 l <br /> L"r A ko— <br /> f f Inspection Date Q /L 0 s <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0P 0P <br /> Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) p <br /> (Fill one only) (Fill all that apply) (Fill all that apply) : (Fill all that apply) <br /> � <br /> IS Active Q Passenger ® Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> O Q Inactive 0 Truck <br /> Longitude _ j 0 End-Use 0 <br /> 9 Q Planned Q OTR 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other y.,,��k, I ►"` <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1 ENFO.RCiMok. BTT � <br /> V A fiA ING-AND MANIFEST REQUIREMENTS <br /> Q Natice Of V16.1016.n ' <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 :PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Q41�d11n5 <br /> Q 0 PRC§42956-Registration/Decal in Vehicle ' <br /> 0 0 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements Q�tg I m ` <br /> Q o 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 daysJK <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years s <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q J�Ifirrlstl7gNlyi % � <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> o 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 0 Other: <br /> Comments L-e�S <br /> ✓ C,_-)11s�,�n-� CLay.t, c�j �i Gwa-'�i7..c �.�4s <br /> p'r —�l+-e�5. �5, 0-6` 10 or <br /> ' s r 4M <br /> Inspection Form Included: 0 <br /> Comments Included: Q — � (v - — - —— <br /> usi s p's S ature hone Number Insp or's Signa ure Phone Number <br /> re�€ nco62o <br /> � M81 <br /> E INSTRUCTIONS ON B CK LCOr <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />