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Waste Tire SurveyP P& Inspection Report Inspection Report Number <br /> State ClWfW(California Survey Form - Page 1 1 1 - 1 0 0 6 6 9 8 <br /> CIWMB 181(New nage <br /> Califomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: � y E/�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address <br /> 1 396 N <br /> Inspection Date Q 2— <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> Latitude O i Q Closed Q Altered <br /> GPS Q Hauler ®Indoor <br /> O Q Inactive 0 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 Govemment 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. <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 IQ 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 1 Other:�./§ <br /> Comments I 1-CDr FSc-tCA ND -Al �4 I,,./s. 0. _'T_7_�__11 <br /> � �_.,L- n!!j _G.. -)-t1_ f 1..1�e s F J ►",a-ms s ��+7� 12-30^�') <br /> -f � k�_[e,e S l * 04;- 00316. 1 lo,, <br /> / -7 DI'?-77 2s er -1-7>//) <br /> 1'�IgM�r IrS 1'\t7-� Oh __.�"i5,►.l'[2�9_'f-" '/r, —/ � ['PlQ O.`o�� f..-w.-.r l �f�l. <br /> Inspection Form Included:Q J <br /> Comments Included:Q <br /> Business Rep's,Signature Phone Number Insp~Sign u Phone Number <br /> INSTRUCTIONS ON BACK J4 M P L E. 1 2 3 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0609004.0349 <br />