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Waste Tire Survey & Inspection Report Inspection Report Numberstate ■ <br /> ClWMl181(omla Survey Form - Page 1 12 . 1 013605 <br /> CNVMB 181 stew 04104) <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 Sufflx: 3 q .2 3 46 0 / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q1L. p/IQCti7f C.0 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> .2-913 Na ,er <br /> Inspection Date � � / / / / O <br /> •!L'•'• �! Time In Time Outt� <br /> Business Rep Title O 9 / 7 O PM 07 �y� �PM <br /> Cre <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4P Active Q Passenger 19 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 10 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 /> 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 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 CLGr Us�y Wwed 44,z[ se" of, j-jl(o.-e ui%,^ y—";­­d aol <br /> 9 wok k"K..e <br /> ��/�` �+au,,• � Go4 d, /uct�,,- no ezu �'rte <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Bus ness ep's ignature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPIL ' 1 3 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br /> 0617904.0411 <br />