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Waste Tire Siu*ey & Inspection Repor* Inspection Report Number <br /> S ate ik C!WM 118`1 tornia purvey Form - Page 1 19 - 1008033 <br /> CfWµa 18i(Naw 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details J <br /> TPIp- - <br /> o � � -2 <br /> 1 , - � r 'Inspection Type (Fill one) <br /> Site Suffix: � -2 `'T f • Routine Q Re-inspection Q Referral Q Observation <br /> Local ��+ r If Referral,choose referral type(Fill one) <br /> Identifier: ., �� Ty Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / <br /> �. inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In v Time Out V <br /> Business Rep Title O AM Q AM <br /> BtA Q ` J p PM Q PM <br /> �} Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C) t t7 t C> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator Outdoor <br /> � Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®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 0 Trucking Fleet Q 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 /> 0 Service Station 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN�L'1R 11 NY�T/��' <br /> i_ A . HAULING AND MAN(_EST REQUIREMENTS <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Irotwojo V 1 Ian I Ill�j�ll�r <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ' <br /> GampUrf,ie z +d �fe , <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 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 I ' <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Y- S+1,�-r+k,�•r !Sir /jµyJ ✓ <br /> Q Q : 14 CCR§18459.3-Retention of Manifest Forms and lire 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§16461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generatorsy IM, <br /> Other: <br /> Comments LJ 1 L, !_X ---�+rW_ 4Jlvs <br /> Inspection Form Included: Q <br /> Comments Included: <br /> O;Business Rep's sturePhone Number or's Signature Phone Number <br /> INSTRUCTIONS ON BACK f O =t Tet: ( i 620131 <br /> _ � EXr�;lillP. L � I � 3 <br /> White Copy: IWMB Yellow Copy:Operator Pink Copy:LEA <br />