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=i Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StateCalifornia Survey Form - Page 1 1 2 1 01 3 1 5 9 <br /> CIWMBMB18 181(New <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / S Inspection Type (Fill one) <br /> Site Suffix: / 7 % e� b - Q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local . ` OIf Referral,choose referral type(Fill one) <br /> Identifier: Q 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �0J � Inspected By Inspector <br /> Physical W.ss <br /> `✓-M ���0 Inspection Date & ( 3 ( Q 7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM _ O PM ; <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � ,�Q <br /> t t 49 Active 0 Passenger I*Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> ®Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § /� e ^,'�_ <br /> Comments j <br /> 9e Gp fL,�it x a e[� '7� <br /> %irr AOSY 46 i'a—lofc w 75 -yT. i J, <br /> y�7f+L p� ice _ ��Ac ✓iii to�� , /� <br /> Inspection Form Included:0 <br /> Comments Included:0 <br /> B InekeWstlgna ur Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK rr 62081 <br /> I�y� � � P L �' 1. 2 3 ® ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0705904.0352 <br />