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u€, Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of 181(N.. Survey Form - Page 1 1 3 . 1 01 0 801 <br /> CIWMB 787(Naw 01/04) <br /> catifomla Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- / b U - O ( Inspection Type (Fill one) <br /> Site Suffix: ' Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local � / � If Referral,choose referral type(Fill one) <br /> Identifier: p/ ,Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility NameIns ected B <br /> L t Q 7JL�tro �Q�Kst.cJr��Gr P Y Inspector �4 <br /> Physical Address 3 9 SUg134„yl40kA <br /> A,, �SaD� Inspection Date 49 S p g O r <br /> (�j� Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> O PM Q PM <br /> 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 /> � <br /> 0 Active •Passenger *Generator *Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 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 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 r <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 1 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments / L�Qe�/ /_ _! •• �frlldu 1 /���L � { /i i <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK K A PA P . E 512131 <br /> ■ 62081 <br /> 0716504.00153 White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ® 0 <br />