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E_ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of <br /> ClWM Survey Form - Page 1 1 6 -- 1 0 1 3 4 6 8 <br /> CIWMB 191(New 04/04) <br /> CaliforniaaliIntegrated Waste Managenage <br /> ment Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: pZ 6 S O Routine Q Re-inspection Q Referral Q Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicAddress 3 9 D / S'ue407x,;Ao"4 <br /> �3 <br /> Inspection Date a 7 6 <br /> Time In Time Out <br /> Business Rep Title / 0 / O PM / O /� AM <br /> Qday /r't4 ZO /"rQGl4 ( C� O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i ' v O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> le Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer 0 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 /> 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 i s rye iI/ , -Vy 44'. GC� 24,W _T"& �i� � ��(✓P4d <br /> /'G/�ipi/taG �Y'� lNe.trf'- a!' d=o, �au,.�zy►�3 ///'Z�ytaQ u�ojt /'Q <br /> u. Zoo w <br /> >4- A . /l10 <br /> Inspection Form Included:Q t <br /> Comments Included:Q `l Ufa <br /> iness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS BACK VIII a ® N4x a L E 1112 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0615104.0432 <br />