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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMBof California Survey Form - Page 1 15 - 1 01 3 319 <br /> CIWMB 781 tew.dl.4) <br /> California Integrated Waste Management Board <br /> Part A-Survey_____ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 7", Lt 3 _ C> 1 Inspection Type (Fill one) -- <br /> Site Suffix: � 1 •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Soh Ocq�Imo— �r CN r,� Q Q Q p Q Q <br /> CHP CIWMB Complaint Educational Visit Other <br /> Business or Facility Name <br /> Inspected By inspector <br /> Physical Address <br /> Inspection Date o L f / C..' S / C) <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> - Operational Status Tire Type Business Role ' Stora Type <br /> Te Te pe <br /> Tire Count(Whole/PTE) « O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' O 40 Active Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) . <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 Q Other <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. ri <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements s <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 h' <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years r` ; <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 1 Q 1 Other. § <br /> Comments 61 `'fit - �7 <br /> da?YfY <br /> 3-7-05, ):12 +4,--,sho--161ho--161 �Ze <br /> i�( �_ _ _ ' <br /> Inspection Form Included:Q, <br /> Comments Included:Qt <br /> B ess Rep's gn hon�Nr �J.t.es Signature Phone Number <br /> INSTRUCTIONS ON CK I V:X A=/Ili P L ] :2 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator V Pink Copy.LEA ® ■ <br /> 0615104.0658 <br />