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= , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> SCalifornia Survey Form - Page 1 1 2 - 10 0 6 5 6 7 <br /> California InCIWMBNVMB 181(Now O4l04)tegrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection D / Inspection Type (Fill one) <br /> Site Suffix: / S 7 0 Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �CZiL �jQQ /y — 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ,-- Inspected By Inspector <br /> Physical Address O / JGC��QO;rV;"` V.4 <br /> Inspection Date D y / / / 6/ <br /> Time In ( Time Out <br /> Business RepTitle / / D *AM / I, A AM <br /> W Z2rAe O PM I r 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 /> ' O Active O Passenger O Generator O Outdoor <br /> 44fGPS Latitude O O Closed O Altered O Hauler O Indoor <br /> O 0Inactive O Truck <br /> Longitude - O End-Use O Container <br /> O Planned O OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder •Other 4eA.I-e Az. <br /> Part B Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility <br /> a t1 'i3 <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle ft s <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements F �y <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> sr�. <br /> x=' <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years F <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 r <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments �t2Err e!' It44 del W 6a44,11 ?y�r-'�' B*t .4 4C , <br /> 4ze - <br /> �L 940" .aw/-, 7�e S.'A ufe-f-Is ,^r�i <br /> etA a.Lr <br /> Inspection Form Included:O / 14444Y. <br /> L-[ � n� �' t"'V�3 <br /> Comments Included: - /��/ J L6 <br /> usi ep's n9h tone Numbac jg <br /> Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK ■ E X A * P L E 1 z 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator) Pink Copy:LEA ® . <br /> 0627704.0062 <br />