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=«= Waste Tire Survey & Inspection Report Inspection Report Number <br /> era <br /> j State or Cal'dornla <br /> CIWM.I M(New 04104) Survey Form - Page 1 1 2 - 1 0 0 6 3 6 9 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE_ OR BLACK INK PEN <br /> Business.Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: 1 S ` O 1 ®Routine Q Re-inspection 0Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: s&-,, 5a t-1VA h (.«.�w�-ti Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> �t 0 <br /> Physica�Address 3 <br /> �`� Inspection Date <br /> Time In Time Out <br /> Business R,,p Title O AM O AM <br /> ``t�W�!►'l. �C.`I���th O 8 PM ') 3 • 1 J ®PM <br /> Operational Statu's:The Type- Business Role -Storage Type <br /> The COUnt(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Z I®Active ®Passenger 0 Generator Q Outdoor <br /> - O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> e New Tire Dealer Q Auto Repair Q 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 /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires c <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration/Decal In Vehicle e <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements r <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB i r <br /> O 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 yearstn f .x2F <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 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 O,1 other: § s T <br /> Comments ^-+ r+ <br /> v t —UV 0,� <br /> 3�a✓w.�� 4 r - rrh <br /> bL h1L1' Z&QwA,.el�s� � LG �1{- t?'6� inb+ <br /> Inspection Form Included:Q <br /> Comments Included;Q ~ <br /> Bu ne 's Signature Phone Number Jn actor s Sig iture;. :. Phone Number <br /> INSTRUCTIONS ON BACK ��� £� , r g p L E 111.213. <br /> 62081 <br /> ,r. .�.._..... M. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0529204. 1055 <br />