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Waste Tire Survey & Inspection Report Inspection Report Number <br /> StateCIWMB <br /> f181INnla Survey Form Page 1 1 - 101346 3 <br /> CIWMB 1t1f(New 04!04) <br /> californla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type ( on <br /> Site Suffix: 36 O5 - Q ' 9Routine QRe-inspection Q Referral Q <br /> Observation <br /> Local &t21,— If Referral,choose referral type(Fill one) <br /> Identifier: �Q�h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name vInspected By Inspector <br /> Z e a A64 sc-f fie./ / O <br /> Physical Address 3 9 / <br /> 1 o s// 41a,411 D-- <br /> J�n`✓ 64n ^6 Inspection Date <br /> H-f`r+^ YJ�i/ Time In Time Out �7 <br /> Business Rep Title O AM (� O AM <br /> O PM / y J y 0 PM <br /> �f— Operational Status Tire Type r Business Role i Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r �•l *Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q 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 <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§184592.1-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 I, C <br /> .1/ayi"n-��f4 ►s . <br /> Inspection Form Included:Q <br /> Comments Included:Q ! y(/ u83 ffc•I C���3 <br /> Business Rep's Signature Phone Number Inspector's Signature ___Phone Number <br /> INSTRUCTIONS ON BACK X A M P .L ] 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 0617904.0413 <br />