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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Slate of CaliforniaSurvey Form - Page 1. 1 3 - 1 Q 3 3 7 4 <br /> CIWMB 187(New 04104)Management Board <br /> Callfomla Integrabd Waeta <br /> Part_A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ?� 3 3 © Q Routine ID Re-inspection Q Referral. Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: aa_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -� <br /> Inspected By Inspector <br /> �7q <br /> Physical Address <br /> J •r�r,^ ,Qectj,l� .�-sl cs�.r 3 9 _ v�-e �+��5 <br /> ddress `1 <br /> � I Zo lel �'►r I�-�-- �-�-- <br /> Inspection Date C> I <br /> —�j.f {o— GA USZc�S <br /> Time In Time Out <br /> Business <br /> //Rep Title Q AM O AM <br /> 0 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply), (Fill all that apply) <br /> t ®Active Q Passenger •Generator I Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler ®Indoor <br /> O Q Inactive ®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 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 ®Other , <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility 1 <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 114 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 1 Other: § <br /> Comments — <br /> �fl2?-'',`,�,9 <br /> D VI"ola'Fiw-y. <br /> Inspection Form Included:Q <br /> Comments Included:Q ---- - <br /> Business Rep's Signature Phone Number Insprctoes Signature Phone Number <br /> 14 <br /> INSTRUCTIONS ON BACK M E X a P l E 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0605204.0541 <br />