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aot <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 18M.4lgdl Survey Form - Page 1. . 1 1 - 1 0 0 6 3 6 8 <br /> California Integrated W-ae1.te 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. , S Routine Q Reinspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: s p�y�J o��} t t� �a l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> Physi al Address 1 7 l rrr"Xt_ Cir-_4 <br /> Inspection Date C' <br /> CA s-3� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O 'Z ' O ay A PM U Z 3 0 e PM <br /> j oy(, Or"irt-t— <br /> Operational Status Tire Type Business Role Storage Type_, <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ° 6 Active IS Passenger ®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 Q End-Use Q Container <br /> Business Type (Fill all that apply). <br /> ®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 /> ��� - -� .+,��. _f .a�� �� t, qtr �'`�. / •> <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> �., <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. } v r} M <br /> Q Q PRC§42956-Registration/Decal in Vehicle x o- <br /> Q Q ' <br /> 14 CCR§18459 -Responsible Entitles Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB "- <br /> - <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ua Sy ' k <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years x ��gs_rss¢rc -Hr <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers r# <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities � tl * <br /> 14-CCR 18462-Manifest stem Requirements for Tire Dealers or Waste Tire Generators <br /> Q - fS ui <br /> § Y q <br /> Q 1 Q .Other. 1 -, + <br /> Comments r oV► I t�S L t-vv t.0 as LLI,1 <br /> yr-�c_.v�b�Ls o s�`(_��D� CZ�$�4��-5>_�l,,,Ilrr����►�. �fs��O�AL-.� \� t�� <br /> U"' `'T <br /> W1 IRVA D'ilh iv. Wvt lS l k <br /> Inspection Form Included:Q 3 <br /> Comments Included:Q <br /> Busi ep's Signature . Phone Number d ector's Signature .. Phone Number. <br /> F0 ,; a�`-e�.w-zs�. 62081 <br /> -INSTRUCTIONS ON BACK E . A hk P 1. 3 <br /> 1, . � <br /> ■ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA - ■ <br /> 0529204. 1054 <br />