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e Waste Tire Survey & Inspection Report Inspection ReportNumber ■ <br /> state of CaliforniaSurvey Form - Page 1 1 6 1 01 3 6 7 4 <br /> CIWMB 781(Nawew04104) <br /> California Integrated Waste Management Board <br /> PartA-Survey - - BLUE OR BLACK INK PEN <br /> Business.Prof91e Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffer: j 0 z 7 y / i Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: sQ� pQj7 CHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name - -- <br /> �� Inspected By Inspector <br /> 'Physical Address 3 <br /> /or_ <br /> � <br /> Inspection Date D JS 'O <br /> Time In Time Out <br /> Business R__ep ''/ Title / /' Q AM 0 AM <br /> ' c Z6/—I 4ee ( -3 7 I e PM ( % / tJ ®PM <br /> Operatlonal Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill ate only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f *Active •Passenger 0 Generates 0 Outdoor <br /> GPS Latitude O ' 0Closed 0Altered <br /> O 0 Inactive •Truck Q Hauler Q Indoor <br /> Longitude — O 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 O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 40 Other <br /> Part B Inspection of Waste Tire Dealer Generator,Hauler and End-Use FacilityNP <br /> i3 �4 X77 <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires iffttiatiQr f <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. .:, <br /> O IPRC§42956-Registration/Decal in Vehicle ;<,cy <br /> O O 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 114 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days4 4 <br /> O O <br /> 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 <br /> O 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 O Other: § <br /> Comments <br /> 941�-` <br /> /�-._ /"a'�[./ �-t.�?"> ill r�l.�/C� �'�1'm �•'"� - —X17/7,X. .il D c<�iq/ <br /> Inspection Form Included;Q' - <br /> Comments Included:Q -�!. � �Z4 blW2-4 4zr - �a✓�—O3 8 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number . <br /> INSTRUCTIONS ON BACK r�HEXIAIMIPILIEI 111213162081 <br /> ■ While Copy.CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br /> 0 r-_.24aA4.6j17 7, <br />