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99 <br /> Waste Tire Survey & Inspection Report InsPection Report Number <br /> State r ClWM of California Survey Form -. Page 1 19 - 1006482. <br /> CIWMB 1g1(New nage <br /> California Inlegretetl Waste Management Board <br /> 'Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details ' <br /> TPID= Inspection Type (Fill.one) <br /> Site Suffix: t ?j 7 -( C l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility`Name <br /> Inspected By I� Inspector <br /> Physical Addre s� <br /> 4.1��ct bCo�soKlp►a' <br /> Inspection Date 0 8 / � � / C) <br /> Time In Time Out <br /> Business Rep Title 41 AM 0 AM <br /> 5 ^fes D O QPM QPM <br /> Lof 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 /> Active 46 Passenger •Generator •Outdoor <br /> O Q Closed: O Altered <br /> GPS Latitude Q Hauler O Indoor <br /> O Q Inactive C ®Truck <br /> Longitude — OPlanned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply).. <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet .Q Government Q Retreader Q Dismantler Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder •Other �ryyVp L Q��N S <br /> Part B,-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal An Vehicle ;K 3 <br /> O Ou, < ' <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 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 r p <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ' <br /> O O 14 CCR§18460.2-Manifest,System Requirements for Registered Waste Tire Haulers o- <br /> O 14 CCR§18461-Manifest System-Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 101 _ <br /> Other: <br /> Comments <br /> v� o✓` S:� tOY` <br /> o Entere$ <br /> Inspection.Form Included:O <br /> Comments Included: <br /> Business R 's.Signature Phone Number In peD! s S'g Phone Number. <br /> INSTRUCTIONS ON BACK L: M � R E X A 1 P• - F 1 2 3 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br /> 0529204. 1173 <br />